COPD and NUTRITIONAL SUPPORT

Sait Karakurt, Assoc. Prof.Sait Karakurt, Assoc. Prof.

Marmara University Medical SchoolMarmara University Medical School

Pulmonary and Critical Care MedicinePulmonary and Critical Care Medicine

COPD- PULMONARY CACHEXIA  definition, prevalence defined as <90 percent ideal body weight)defined as <90 percent ideal body weight)

the prevalencethe prevalence 30-70 %. 30-70 %.

More common in patients required More common in patients required mechanical ventilationmechanical ventilation

COPD-malnutrition and mortality

Chailleux, E, Laaban, J-P, Veale, D. Prognostic value of nutritional depletion in patients with COPD treated by long-term oxygen therapy. Chest 2003; 123:1463

Metabolism and caloric intakeMetabolism and caloric intake  

AgingAging

Exercise Exercise 

HypoxiaHypoxia

InflammationInflammation (TNF alfa, IL6) (TNF alfa, IL6)

MedicationsMedications

COPD- PULMONARY CACHEXIA

Contributing factors 

COPD-malnutrition-muscle

Kelsen, SG, Ference, M, Dapoor, S, J Appl Phsiol 1985; 58:1354.

COPD-muscle strength -CO2

Carbon dioxide retention begins when Carbon dioxide retention begins when respiratory muscle strength is <50 respiratory muscle strength is <50 percent of normal and becomes marked percent of normal and becomes marked when respiratory muscle strength is <25 when respiratory muscle strength is <25 to 35 percent of normal in individuals to 35 percent of normal in individuals without lung diseasewithout lung disease

Malnutrition- deleterious effects

Wound healingWound healing Intestinal mucosal atrophyIntestinal mucosal atrophy Decrease in muscle massDecrease in muscle mass Diminished immune competenceDiminished immune competence Development of edemaDevelopment of edema

Anabolic metabolism in muscle

METABOLIC RESPONSE in CRITICAL PATIENT

Jeevanandan M et al. JPEN 1992;16:511-520

COPD-Treatment Optimization of lung function Optimization of lung function

Regular exercise, which has been shown to improve the Regular exercise, which has been shown to improve the effectiveness of nutritional therapy and to stimulate effectiveness of nutritional therapy and to stimulate appetiteappetite

Improvement of oxygen delivery through Improvement of oxygen delivery through oxygenoxygen therapytherapy, correction of anemia, and/or optimization of , correction of anemia, and/or optimization of cardiac function cardiac function

Control of inflammation as much as possible, while Control of inflammation as much as possible, while limiting oral corticosteroid uselimiting oral corticosteroid use

COPD-Nutritional therapy  Adequate calories to meet their basal energy Adequate calories to meet their basal energy

expenditure expenditure

Small, frequent meals with nutrient-dense foods (eg, Small, frequent meals with nutrient-dense foods (eg, eggs) eggs)

Meals requiring little preparation (eg, microwaveable) Meals requiring little preparation (eg, microwaveable)

Rest before meals Rest before meals

Daily multivitaminDaily multivitamin

ENERGY SOURCES

Main source is lipids.Main source is lipids.

Protein is not stored.Protein is not stored.

Carbohydrates are stored in liver as Carbohydrates are stored in liver as glycogen and 1 day requirement is glycogen and 1 day requirement is probable. probable.

ASSESSMENT of NUTRITIONAL STATUS HistoryHistory

Weight loss 10% in last 6 months, 5% in last month Weight loss 10% in last 6 months, 5% in last month Physical examinationPhysical examination

InspectionInspection Antropometric measurementsAntropometric measurements Muscle strenghtMuscle strenght

LabLab Serum albumin, prealbumin, transferrin, retinol Serum albumin, prealbumin, transferrin, retinol

binding proteinbinding protein Lymphocyte count Lymphocyte count Nitrogene balanceNitrogene balance

Basal Energy RequirementsHarris-Benedict formula(kcal/day)

MenMen 66+(13.7xW)+(5xH)-(6.8xA)66+(13.7xW)+(5xH)-(6.8xA)

WomanWoman 665+(9.6xW)+(1.8xH)-(4.7xA)665+(9.6xW)+(1.8xH)-(4.7xA)

Body weight (kg)Body weight (kg) H=height (cm)H=height (cm) A=age(year)A=age(year)

Basal Energy Requirements BMI

-BMI-BMI(kg/m2) (kg/m2) Energy requirement Energy requirement (kcal/kg/day)(kcal/kg/day)

<15<15 35-4035-4015-1915-19 30-3530-3520-2920-29 20-2520-25>30>30 15-2015-20

900 kcal/m2/day (man), 850 kcal/m2/gün (woman)900 kcal/m2/day (man), 850 kcal/m2/gün (woman)

25-35 kcal/kg25-35 kcal/kg

Measurement of total calori

For maintenenceFor maintenence

1.5xBEE1.5xBEE

For anabolic effectFor anabolic effect

1.8xBEE1.8xBEE

COPD-nutritional support

High carbohydrate intake may result in COHigh carbohydrate intake may result in CO22 retension in respiratory failureretension in respiratory failure

R/Q (COR/Q (CO22 production/O production/O22 delivery) delivery) R/Q=1 (carbohydrate) R/Q=1 (carbohydrate) R/Q=0.8 (protein) R/Q=0.8 (protein) R/Q=0.7 (fat) R/Q=0.7 (fat) R/Q>1 (shows execcive carbohydrate intake)R/Q>1 (shows execcive carbohydrate intake)

COPD-calori intake -CO2 production

Talpers, S, Romberger, D, Bunce, S, et al, Chest 1992; 102:551

COPD-nutritional support

Fat/carbohydrate 3/1Fat/carbohydrate 3/1 Fat ratio should be 15-40% of total Fat ratio should be 15-40% of total

calori calori Megestrol asetat, 800mg/dayMegestrol asetat, 800mg/day Oxandrolon 10 mg, bidOxandrolon 10 mg, bid Glutamin, arginin, omega 3 are not Glutamin, arginin, omega 3 are not

routine (Level IIB)routine (Level IIB)

COPD-nutritional support Patients with advanced lung disease should receive a caloric intake Patients with advanced lung disease should receive a caloric intake

that matches estimated energy expenditure, in order to avoid that matches estimated energy expenditure, in order to avoid excess CO2 production, (1.5xBEE).excess CO2 production, (1.5xBEE).

Mixed carbohydrate-fat diets in which fat comprises 20 to 40 Mixed carbohydrate-fat diets in which fat comprises 20 to 40 percent of the total calories should be used preferentially percent of the total calories should be used preferentially

The use of very high fat (>40 percent) or very low fat (<15 The use of very high fat (>40 percent) or very low fat (<15 percent) diets is not recommended; the former is poorly tolerated percent) diets is not recommended; the former is poorly tolerated and can result in diarrhea and abdominal discomfort, while the and can result in diarrhea and abdominal discomfort, while the latter increases CO2 production and does not deliver enough latter increases CO2 production and does not deliver enough essential fatty acids.essential fatty acids.

BESLENME DESTEĞİNİN MONİTÖRİZASYONU1-Elektrolit, asit-baz 1-Elektrolit, asit-baz -kan gazları -kan gazları endike oldukça endike oldukça

-Na,Cl,K,HCO3 -Na,Cl,K,HCO3 qdx3, qdx3, qwqw

-Mg,Ca,PO4-Mg,Ca,PO4 2 haftada bir 2 haftada bir-İdrar elektrolit-İdrar elektrolit endike oldukça endike oldukça

2-Glukoz toleransı2-Glukoz toleransı -glukoz-glukoz günlük günlük -idrar glukoz,keton -idrar glukoz,keton 6 saatte bir 6 saatte bir

3-Yağ toleransı3-Yağ toleransı -makroskopik lipemi -makroskopik lipemi her kan alınışta her kan alınışta-trigliserid-trigliserid haftada bir haftada bir

4-Sıvı dengesi4-Sıvı dengesi -BUN,kreatinin-BUN,kreatinin 2 haftada bir 2 haftada bir-Vücut ağılığı-Vücut ağılığı günlük günlük-Hematokrit-Hematokrit 2 haftada bir 2 haftada bir-Vital bulgular-Vital bulgular 6 saatte bir 6 saatte bir-Aldığı çıkardığı sıvı-Aldığı çıkardığı sıvı günlük günlük

5-Böbrek ve karaciğer5-Böbrek ve karaciğer -BUN, kreatinin-BUN, kreatinin 2 haftada bir 2 haftada birFonksiyonlarıFonksiyonları -AST,AF,bilirübin-AST,AF,bilirübin 2 haftada bir 2 haftada bir

BESLENME DESTEĞİNİN MONİTÖRİZASYONU6-Beslenme durumu6-Beslenme durumu kalori-protein alımı kalori-protein alımı günlük günlük

vücut ağırlığıvücut ağırlığı günlük günlük

azot dengesiazot dengesi haftada bir haftada bir

serum albüminserum albümin haftada bir haftada bir

serum esansiyel yağ asiti endike oldukçaserum esansiyel yağ asiti endike oldukça

serum eser elementleri endike oldukçaserum eser elementleri endike oldukça

serum transferrinserum transferrin haftada bir haftada bir

serum vitaminserum vitamin endike oldukça endike oldukça