• Chronic Obstructive Pulmonary Diseaseo  Progresive obstruction of airways

• Emphysemao Desruction of alveoli wallso Abnormal and permanent elargement of alveoli

• Chronic Bronchitiso chronic and productive cougho Inflammation of bronchi

• Decreased recoil of alveoli Decreased recoil of alveoli wallswalls

• IrreversibleIrreversible• Causes difficulty exhalingCauses difficulty exhaling

o Leads to hypercapniaLeads to hypercapnia• Mild hypoxemia and normal Mild hypoxemia and normal

HematocrytHematocryt• Can lead to Cor PulmonaleCan lead to Cor Pulmonale

o Right sided heart failure Right sided heart failure due to enlargement of due to enlargement of vesicles brought on by vesicles brought on by stress associated with stress associated with chronic lung diseasechronic lung disease

  

• Typical Patient: older, thin, smokers

• Inflammation of bronchi due to changes in Inflammation of bronchi due to changes in lung tissueslung tissues

• Hypoxemia and elevated HematocrytHypoxemia and elevated Hematocryt• Development of Cor Pulmonale occurs Development of Cor Pulmonale occurs

earlyearly  • Typical Patient: Normal to overweight Typical Patient: Normal to overweight

• Tobacco smokeTobacco smoke• Environmental pollutionEnvironmental pollution• GeneticsGenetics

Medications for Treatment• Bronchodialators

o Decrease shortness of breath by opening and relaxing airways

• Coticosteroidso Can be inhaled or in pill formo Decrease inflamation of bronchi

• Patients have increased resting energy expenditure

•125%-156% above BEE

•Protein 1.2-1.7 g/kg

•In hospital pt usually requires support feeding

•Recommend vitamin consumption: C, A , E and Beta Carotene

Catabolic/Anabolic Balance and Muscle Wasting in Patients With COPD.

• Evaluated the relationship between levels of catabolic Evaluated the relationship between levels of catabolic factors(interleukin, cortisol), anabolic factors (bioavailable testosterone, factors(interleukin, cortisol), anabolic factors (bioavailable testosterone, dehydroepiandrosterone sulfate, and insulin-like growth factor), and dehydroepiandrosterone sulfate, and insulin-like growth factor), and mid-thigh muscle cross-sectional area in patients with mid-thigh muscle cross-sectional area in patients with COPD COPD to classify to classify levels of muscle wastinglevels of muscle wasting

•   45 men diagnosed with COPD and 16 healthy, sedentary men 45 men diagnosed with COPD and 16 healthy, sedentary men participatedparticipated

• 22% of participants with COPD exhibited elevated levels of testosterone 22% of participants with COPD exhibited elevated levels of testosterone (campared to 0% of control)(campared to 0% of control)

•   COPD patients had lower DHEAS levels than healthy participantsCOPD patients had lower DHEAS levels than healthy participants• Ratios of catabolic factors to anabolic factors were greater in COPD Ratios of catabolic factors to anabolic factors were greater in COPD

patientspatientso Shifting toward a catabolic state and possible muscle wastingShifting toward a catabolic state and possible muscle wasting

•   Debigaré, Richard; Marquis, Karine; Côté, Claude H.; Tremblay, Roland Debigaré, Richard; Marquis, Karine; Côté, Claude H.; Tremblay, Roland R.; Michaud, Annie; LeBlanc, Pierre; Maltais, François. R.; Michaud, Annie; LeBlanc, Pierre; Maltais, François. Catabolic/Anabolic Balance and Muscle Wasting in Patients with COPD. Catabolic/Anabolic Balance and Muscle Wasting in Patients with COPD. CHEST, Jul2003, Vol. 124 Issue 1, p83CHEST, Jul2003, Vol. 124 Issue 1, p83

Dietary support to underweight patients with end-stage pulmonary disease assessed for lung transplantation

• Randomized Control Study •Test 71 paitents

•49 Under weight •29 Normal weight

• Study found that underweight group given a calorie dense meal with supplement lead to an average of 1.2 kg weight gain in 13 days

Both generic and disease specific health-related quality of life are deteriorated in patients with underweight COPD.

• Cohort Study

• Patients were COPD stable and getting once a month check- ups • Study Found that underweight participants had a lower quality of life rating due to shortness of breath, inability to exercise and bodily pain

Investigation into the nutritional status, dietary intake and smoking habits of patients with chronic obstructive pulmonary disease.

• Cross Sectional Study

• Split 103 participants into 2 groups: Nourished and Malnourished

• Malnourished group•Lower lung function •More Dietary problems •Lower nutritional intake compared to counter parts

Age: 65

Sex: Male

Chief Complaint:

Shortness of breath due to emphysema

Medical History:

Emphysema 10 years

COPD due to Tobacco Use

Admitting Medical Diagnosis:

Chest Radiograph shows tension pneumothorax in left lung

Daishi Hayato

Family status: Married, four grown Children•Wife prepares meals •She reports appetite decline in past several weeks

Ethnicity: Asian American

Education: Bachelor’s Degree

Occupation: Retired Grocery Store Manager

Religious Affiliation: Methodist

Smokes 2 ppd for past 50 years •Continues to smoke

Ht: 64” BMI: 20.9 normal

Wt: 122 lbs IBW: 130 lbs

UBW: 135 %IBW: 94% normal

% UBW: 90% mildly depleted energy stores

Anthropometrics

Vitals Respiration Rate: 36 breaths per min Blood Pressure: 110/ 80 Temperature: 97.6 °F Heart Rate: 118 bpm

LDL/ HDL : 142/32

Allergies Penicillin

•COPD secondary to tobacco use

•Emphysema diagnosed more than 10 yrs ago

• Cholecystectomy 20 yrs ago

• Total dental extraction 5 yrs ago

• Intermittent claudication

•Reports swelling in lower extremities

• History of dyspnea

•Two pillow orthopnea

• Family History

•Father suffered from lung cancer

Combivent Inhaler - 2 inhalations 4x a day• Bronchiodilator • Potential risk if allergic to: peanuts, soy and soy lecithin• Caution if taken with diuretics

Lasix – 40 mg daily • Diuretic • Decrease strain on blood vessels and heart• May reduce potassium levels in blood • Increase sensitivity to sun

Oxygen – 2 L/hr via nasal cannula only at night

Usual Intake • Breakfast

•Egg•Hot Cereal •Bread or Muffin •Hot Tea w/ milk and sugar

•Lunch•Soup •Sandwich •Hot Tea w/ milk and sugar

•Dinner•Small amount of Meat •Rice •2-3 types of Vegetables•Hot Tea w/ milk and sugar

* No known food allergies

24 Hour Recall•Breakfast

•2 scrambled Eggs•Few bites cream of wheat •Bite of toast •Sips of hot tea throughout the day

•Ate Nothing Else • Estimated Calorie Intake: 400-500 calories

Kcal needs: (66.5 + (13.8 x 55.45kg) + (5 x 137.16 cm) – (6 x 65)) x 1.2 x 1.6 = 2165 kcals

* No Daily Vitamin Intake

According to the American Lung Association a person with COPD requires 10 times as many calories to breathe than a healthy person. (Trendel)

Pros: •Allows for adequate calorie intake

• Provides for sufficient high protein needs

•Gives patient fluids

•Maintains integrity of the gut!

•Eliminates meal time stress (Katsura et al 2005)

Cons: •Discomfort for patient

Inadequate oral food and beverage intake (NI-2.1) related to difficulty swallowing (NI-1.1) due to dyspnea as evidenced by unintentional weight loss of 13 lbs, patient food recall and limited appetite.

ND-1: Modify distribution, type, or amount of food and nutrients within meals or specified time

1. Diet • Small frequent calorically dense meals high in protein

• 15-20% Protein • 30-45% Fat • 40-55% Carbohydrates

• Avoid foods that lower LES pressure (Barrett)• Avoid gas producing foods that cause stomach to push on diaphragm• Avoid sodas • Avoid alcohol • Eat slowly, chew well, rest before meal time • Use Oxygen during and after meal time (Wouters) • Add a dietary supplement at meal time (Forli et al 2001)

• Especially Vitamin C

• Breakfast: •Eggs • Oatmeal with Peanut Butter•Whole Wheat toast with Peanut Butter •Orange Juice •Hot Tea (caffeine Free) with multivitamin

•Mid Morning Snack •Ensure

•Lunch •Usual Sandwich •Yogurt•Hot Tea

•Mid Afternoon Snack •Rice and Beans •Water

•Dinner•Meat (in small pieces) •Veggies •Mashed potatoes •Hot Tea

1. Supplemental Feeding• High Protein, High Calorie supplemental

2. Nutrition Education• Suggest trying to limit smoking ? • Educate what are gas producing foods • Foods that lower LES pressure • Smart eating behavior • Encourage family support and involvement

Short Term • Prevent additional weight loss • Regain 5 lbs within 1 month •Increase food intake to minimum caloric needs of 2165 kcals per day

Long Term • Return UBW within 6 months • Increase physical activity to 15 minutes a day

Monitor and Evaluation of Goals: • Patient to return in 2 weeks with wife to check anthropometrics, food intake

and diet tolerance • Once significant progress change to monthly check up

Katsura H, Yamada K, Kida K. Both generic and disease specific health-related quality of life are deteriorated in patients with underweight COPD. Respiratory Medicine 2005;99:624-30.

Forli L, Pedersen JI, Bjortuft O, Vatn M, Boe J.  Dietary support to underweight patients with end-stage pulmonary disease assessed for lung transplantation.  Respiration 2001;68(1):51-7.

Regional COPD Working Group. COPD prevalence in 12 Asia–Pacific countries and regions: Projections based on the COPD prevalence estimation model. Respirology. June 2003, Vol. 8, Issue 2, Pgs. 192-198

Cai B, Zhu Y, Ma Y, Xu Z, Zao Y, Wang J, Lin Y, Comer GM.  Effect of supplementing a high-fat, low-carbohydrate enteral formula in COPD patients.  Nutrition 2003;19(3):229-232.

Wouters, Emil, Creutzberg, Eva, Schols, Annemie. Systemic Effects in COPD. CHEST May 2002. Vol 121, Issue 5 Supplement. Pgs. 127S-130S

More References

Debigaré, Richard; Marquis, Karine; Côté, Claude H.; Tremblay, Roland R.; Debigaré, Richard; Marquis, Karine; Côté, Claude H.; Tremblay, Roland R.; Michaud, Annie; LeBlanc, Pierre; Maltais, François. Michaud, Annie; LeBlanc, Pierre; Maltais, François. Catabolic/Anabolic Catabolic/Anabolic Balance and Muscle Wasting in Patients with COPD. Balance and Muscle Wasting in Patients with COPD. CHEST, Jul2003, Vol. CHEST, Jul2003, Vol. 124 Issue 1, p83124 Issue 1, p83

Cochrane WJ, Afolabi OA.  Investigation into the nutritional status, Cochrane WJ, Afolabi OA.  Investigation into the nutritional status, dietary intake and smoking habits of patients with chronic dietary intake and smoking habits of patients with chronic obstructive pulmonary disease.  J Hum Nutr Diet 2004;17(1):3-11obstructive pulmonary disease.  J Hum Nutr Diet 2004;17(1):3-11