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

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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.