Post on 30-Mar-2015
NUTRITION CONSIDERATIONS FOR PULMONARY DISEASES
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What do we mean by “Pulmonary Disease”
For this presentation, “Pulmonary Disease” includes:
1. Diseases that directly decrease pulmonary function: COPD, asthma, etc…
2. Diseases that indirectly decrease pulmonary function: Neurological diseases, such as ALS, that eventually lead to
permanent vent dependence Acute Respiratory Distress Syndrome Developmental diseases, such as Cerebral Palsy
OBJECTIVES
Understand the relationship between poor nutrition and pulmonary function and vice versa.
Know what parameters to monitor a patient’s nutritional status during pulmonary disease or times of decreased pulmonary function
Know how someone’s energy and macronutrient needs change when pulmonary function decreases
Identify the nutritional risks or considerations of aspiration, refeeding syndrome, and weaning from a ventilator
Identify common medications used for decreased pulmonary function and their associated nutritional complications
How Poor Nutrition Affects Pulmonary Function
Malnutrition adversely affects: lung structure elasticity respiratory muscle mass and strength lung immune function control of breathing
Examples: Respiratory muscles break down, just as skeletal
muscles do, in times of starvation or stress
Hypoproteinemia contributes to pulmonary edema by decreasing osmotic pressure
Decreasing surfactant contributes to the collapse of alveoli and increases the work of breathing
The supporting connective tissue of the lungs is composed of collagen, which requires vitamin C for synthesis
Malnutrition, leading to decreased immunity, increases risk of respiratory infections
L.K. Mahan, S. E. Escott-Stump. 2008. Krause’s Food & Nutrition Therapy, 12 th Edition. Saunders Elsevier. St. Louis, Missouri. pg 901-919.
1. Decreased pulmonary function increases a person’s nutritional needs
How Pulmonary Status Affects Nutrition
Due to: Increased effort required from pulmonary muscles to
breathe Increased incidence of chronic infections
Being sick increases a person’s nutritional requirements
2. Decreased pulmonary function decreases a person’s oral intake of food and nutrients
2. Decreased pulmonary function decreases a person’s oral intake of food and nutrients
Due to: Shortness of breathe and decreased O2 sat while
eating decreases appetite Anorexia associated with chronic disease GI distress and vomiting Pulmonary edema necessitates fluid restriction,
limiting calories from juices, pop, milk, and other beverages
Decreased pulmonary function causes general fatigue, making food preparation difficult
How Pulmonary Status Affects Nutrition
A V
iciou
s Cycle
L.K. Mahan, S. E. Escott-Stump. 2008. Krause’s Food & Nutrition Therapy, 12 th Edition. Saunders Elsevier. St. Louis, Missouri. pg 901-919.
“From quality awareness, comes quality of life”
~Unknown
Goal of Nutrition
Therapy during pulmonary
disease:
To prevent or minimize loss of
respiratory muscle mass and
maximize pulmonary
function, while at the same time
providing maintenance or
repletion therapyAmerican Society for Parenteral and Enteral Nutrition. 2008. Nutrition Support Core Curriculum: a case-based approach---The Adult Patient. Editor: M.M. Gottschlich.
Silver Spring, MD. Pg 489-497. Picture courtesy of : www.careinfusion.com
Parameters to assess and monitor nutrition status
L.K. Mahan, S. E. Escott-Stump. 2008. Krause’s Food & Nutrition Therapy, 12 th Edition. Saunders Elsevier. St. Louis, Missouri. pg 901-919.
Nutritional Requirements
GOAL: Meet caloric needs without overfeedingGOAL: Meet caloric needs without overfeeding
Pulmonary patients typically have increased
caloric needs;HOWEVER, overfeeding
increases strain on pulmonary system and can lead to decreased
function
General Guideline:25-30 calories per kg body weight
Example:Patient X weighs 160 pounds and is 45
yo. Step 1. Divide by 2.2 to find weight in
kg (160 / 2.2 = 72.7 kg) Step 2. Multiply by 30 to find daily
calorie needs
What do I use for body weight?-If patient is experiencing a great deal of
edema, use patient’s usual “dry” weight
-If patient is obese, you must adjust the body weight to avoid overfeeding
Caloric Needs
American Society for Parenteral and Enteral Nutrition. 2008. Nutrition Support Core Curriculum: a case-based approach---The Adult Patient. Editor: M.M. Gottschlich. Silver Spring, MD. Pg 489-497.
Protein needs are slightly increased in patients with pulmonary disease
Protein needs are slightly increased in patients with pulmonary disease
Protein Needs
American Society for Parenteral and Enteral Nutrition. 2008. Nutrition Support Core Curriculum: a case-based approach---The Adult Patient. Editor: M.M. Gottschlich. Silver Spring, MD. Pg 489-497.
How much food is 87-109 grams of protein?How much food is 87-109 grams of protein?
Protein Needs
Recommend high fat, low carb diet when trying to wean or during periods of acute respiratory distressRecommend high fat, low carb diet when trying to
wean or during periods of acute respiratory distress
Recommend the following ratios: Protein: 15-20% of
total calories Fat: 30-45% of total
calories Carbohydrate: 40-55%
of total calories
Excess carbohydrate increases CO2 production and increases patient’s reliance on assistance
Fat and Carbohydrate Needs
American Society for Parenteral and Enteral Nutrition. 2008. Nutrition Support Core Curriculum: a case-based approach---The Adult Patient. Editor: M.M. Gottschlich. Silver Spring, MD. Pg 489-497.
Disease-Specific Enteral Formulation
Most common formulas include Oxepa and Pulmocare
There is limited evidence that pulmonary formulas (high fat, low carb) have clinically significant benefits compared to standard or nutrient-dense formulas that provide adequate energy, regardless of carbohydrate to fat ratio.
Overfeeding calories has a greater impact on CO2 production than high carb feedings
We stress providing accurate calories rather than low carb formulas.
High fat formulas are generally less tolerated than standard formulas (This means patients typically have high residuals and feel uncomfortable because fat decreases motility and sticks around in the gut longer)
Standard formulas are much less expensive and often have better coverage by insurance companies.
American Society for Parenteral and Enteral Nutrition. 2008. Nutrition Support Core Curriculum: a case-based approach---The Adult Patient. Editor: M.M. Gottschlich. Silver Spring, MD. Pg 489-497.
Nutrition-Related Considerations for Pulmonary Disease
1.Aspiration
2. Re-feeding Syndrome
3. Weaning from a ventilator
Aspiration
Aspiration is the main cause for respiratory infections, particularly pneumonia
These increase the risk for aspiration: High residuals Gastroparesis or impaired gastric motility Difficulty swallowing or chewing
Strategies to prevent aspiration: Increase the head of bed to at least 30 degrees, preferably
45 Vent stomach before feeding Control secretions
Re-Feeding Syndrome
Refers to the drastic drop in plasma electrolytes following the reintroduction of adequate nutrition to a severely malnourished patient Most pulmonary patients are malnourished to some degree as
their disease progresses
Can occur in the first week of feeding adequate nutrition to those who have been significantly malnourished for a long time
Characterized by low serum K+, Mg+, P+
Can cause heart failure and/or resp. failure
Avoided by gradual reintroduction of nutrition
Weaning from a ventilator
Primary reason for prolonged vent dependence is pulmonary failure
However, dependence has been linked to both overfeeding and underfeeding
Nutrition goal: Feeding adequate nutrition without excessive calories
Excessive CO2 production increases minute ventilation to reduce PCO2
PATIENTS WITH PULMONARY DISEASE ARE AT NUTRITION RISK AND SHOULD UNDERGO NUTRITION SCREENING TO IDENTIFY THOSE WHO REQUIRE FORMAL NUTRITION ASSESSMENT AND A PLAN OF CARE
ENERGY INTAKE SHOULD BE KEPT AT OR BELOW ESTIMATED NEEDS
ROUTINE USE OF MODIFIED CARBOHYDRATE AND FAT NUTRITION FORMULATION IS NOT WARRANTED
SERUM PHOSPHATE LEVELS SHOULD BE MONITORED CLOSELY IN THESE PATIENTS
Review: ASPEN Nutrition Guidelines for Pulmonary
Diseases
American Society for Parenteral and Enteral Nutrition. 2008. Nutrition Support Core Curriculum: a case-based approach---The Adult Patient. Editor: M.M. Gottschlich. Silver Spring, MD. Pg 489-497.
Pulmonary Medication Interactions
Bronchodilators relax smooth muscles Ex. Albuterol
Antibiotics Protect against infections
Anticholinergic
Anti-histamines Ex. Benedryl Suppress allergic response to
stimuli
Anti-inflammatory agents Corticosteroids (Prednisone) Suppress airway
inflammation
Side Effects: dry mouth/throat nausea vomiting diarrhea hand tremors headache dizziness GERD
The big one: Corticosteroids
Creates increased appetite and insomnia Long term: weight gain
Insulin resistance: Long term: hyperglycemia
Sodium retention: Long term: fluid retention
and edema
Creates negative Ca++ balance Long term: risk for
osteoporosis
CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)
A Closer Look:
Nutritional Complications specific to COPD
Decreased food intake Due to:
Morning headache and confusion from hypercapnia Fatigue Anorexia from lack of oxygen Difficulty chewing and swallowing from dyspnea
Increased nutritional needs Due to:
Degree of airflow obstruction increasing work of breathing Gas diffusing capacity, CO2 retention, and inflammation induce
hormones and cytokines that increase metabolic needs
Constipation or Diarrhea Due to:
Low fiber intake (constipation) Impaired peristalsis secondary to lack of O2 to GI tract (diarrhea)
GOALS of Nutrition Therapy specific to COPD
Maintain optimal energy balance to preserve visceral and somatic proteins. COPD patients have been shown to need 94-146% calories as
a healthy individual of similar size. Avoid overfeeding, which reduces pulmonary fxn
Optimize macro-and micronutrient intakes Adequate fluid, fiber, and exercise can ease constipation Proper balance of protein, fat, and CHO can improve
pulmonary fxn Meet the dietary guidelines for Mg+ and P+ to aid in muscle
contraction and relaxation Monitor risk for osteoporosis, as DEXA scans have
demonstrated that those with COPD to have reduced bone density
TIPS and TRICKS for coping with COPD
If bloating is a problem, avoid foods associated with gas formation
Rest before meals
Eat small, frequent meals of energy-dense foods
Eat slowly, chew foods well
Engage in social interaction during meals
Link with community resources Meals on Wheels and congregate meal programs
A closer look at: Asthma
Nutrition implications specific to Asthma
Etiology is yet unclear
Nutritional factors, such as maternal diet during pregnancy, diet during infancy and toddlerhood,
and obesity “have been hypothesized to be implicated with” asthma---Vague!
Asthmatic symptoms may be aggravated by allergen exposure, including certain foods, such as: shrimp, food additives (such as sulfites), and
botanicals (such as citronella in insect repellents, rusty-leafed rhododendron in natural honeys, and
strawberry leaf in herbal teas)
Foods and/or nutrients currently being studied to aid in asthma
treatment
Omega 3 and Omega 6 fatty acids
(Decrease production of bronchoconstrictive leukotrienes)
Antioxidant nutrients
(Protect airway tissues from oxidative stress)
Magnesium
(smooth-muscle relaxant and anti-inflammatory agent)
Methylxanthiness, such as caffeine
(bronchodilator)
GOALS of Nutrition Therapy specific to Asthma
Individual evaluation for environmental triggers
Diet of wholesome foods to provide optimal energy, nutrients, and phytonutrients
Correction of diagnosed energy and nutrient deficiencies or excesses
Medication-food-nutrient interactions
Thank you for participating!
To take the posttest for this course click here. Once you have completed
the posttest, you can email it to nutrition@reliamed.com or fax it to 763-255-3956.