1
Q
Malnutrition in regards to the pulmonary system impairs:
A
- Respiratory muscle function
- Ventilatory drive
- Response to hypoxia
- Pulmonary defense mechanisms
2
Q
Effects of malnutrition in pts without lung disease:
A
- Respiratory muscle strength decreased by 37%
- Maximum voluntary ventilation decreased by 41%
- Vital capacity (lung volume) decreased by 63%
- Diaphragmatic muscle mass decreased to 60% of normal in underweight pts who died of other ailments
3
Q
Effects of malnutrition in pts with pulmonary disease:
A
- Decreased cough and inability to mobilize secretions
- Atelectasis and pneumonia
- Prolonged mechanical ventilation and difficulty weaning with prolonged ICU stay
- 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
4
Q
Chronic Pulmonary Disorders
A
- Bronchopulmonary displasia
- Cystic fibrosis
- Tuberculosis
- Bronchial asthma
- Chronic obstructive pulmonary disease (COPD)
5
Q
Acute Pulmonary Disorders
A
- Pulmonary aspiration
- Pneumonia
- Tuberculosis
- Cancer of the lung
- Acute respiratory distress syndrome
- Pulmonary failure
6
Q
Adverse effects of increased energy expenditure on lung disease:
A
- Increased work of breathing
- Chronic infection
- Medical treatments (e.g. bronchodilators, chest physical therapy)
7
Q
Adverse effects of reduced intake on lung disease:
A
- Fluid restriction
- SOB
- Decreased oxygen saturation when eating
- Anorexia due to chronic disease
- Gastrointestinal distress and vomiting
8
Q
Bronchopulmonary Dysplasia (BPD)
A
Chronic lung condition in newborns that often follows respiratory distress syndrome (RDS) and treatment with oxygen. Occurs most frequently in infants who are premature or low birth weight.
9
Q
BPD Signs and Symptoms
A
- Hypercapnea (CO2 retention)
- Tachypnea
- Wheezing
- Dyspnea
- Recurrent respiratory infections
- Cor pulmonale (right ventricular enlargement of the heart)
10
Q
Growth Failure in BPD
A
- Increased energy needs
- Inadequate dietary intake
- Gastroesophageal reflux
- Emotional deprivation
- Chronic hypoxia
11
Q
Goals of Nutritional Management in BPD
A
- Meet nutritional needs
- Promote linear growth
- Develop age-appropriate feeding skills
- Maintain fluid balance
12
Q
Energy Needs in BPD
A
- 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
13
Q
Protein Needs in Babies with BPD
A
- Protein should be within advised range for infants of comparable post-conceptional age
- As energy density of the diet is increased by the addition of fat and CHO, protein should still provide 7% or more of total kcals
14
Q
Macronutrient Mix in BPD
A
- Fat and CHO 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 CHO is limited
- Excess CHO increases RQ and CO2 output
15
Q
Fluid in BPD
A
- Infants with BPD may require fluid restriction, Na restriction, and long term treatment with diuretics
- Use of parenteral lipids or calorically dense enteral feeds may help the infant meet energy needs
16
Q
Mineral Needs in BPD
A
- Often driven by the baby’s premature status
- Lack of mineral stores as a result of prematurity (Fe, Zn, Ca)
- Growth delay
- Medications like diuretics, bronchodilators, antibiotics, cardiac antiarrhythmics, and corticosteroids are associated with loss of minerals including chloride, potassium, and calcium
17
Q
Vitamin Needs in BPD
A
- 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 catch-up growth
18
Q
Feeding Strategies in BPD
A
- 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
19
Q
Feeding Strategies in GERD
A
- Thickened feedings (add rice cereal to formula)
- Upright positioning
- Medications like antacids or histamine H2 blockers
- Surgical fundoplication
20
Q
Long Term Feeding Problems in BPD
A
- History of unpleasant oral experiences (intubation, frequent suctioning, recurrent emesis)
- 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
21
Q
Cystic Fibrosis (CF)
A
Epithelial cells and exocrine glands secrete abnormal mucus that is thick. CF affects respiratory tract, sweat, salivary, intestine, pancreas, liver, reproductive
22
Q
Diagnosis of CF
A
- 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
23
Q
Nutritional Implications of CF
A
- Infants born with meconium ileus are highly likely to have CF
- 85% of persons with CF have pancreatic insufficiency because plugs of mucus reduce the digestive enzymes released from the pancreas causing maldigestion of food and malabsorption of nutrients
- 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
24
Q
Nutritional Care Goals in CF
A
- Control malabsorption
- Provide adequate nutrients for growth or maintain weight for height or pulmonary function
- Prevent nutritional deifciencies
25
Common Treatments for CF
- Pancreatic enzyme replacement
- Adjust macronutrients for symptoms
- Nutrients for growth
26
Pancreatic Enzyme Replacement
Enteric-coated enzyme microspheres withstand acidic environment of the stomach. They release enzymes in the duodenum, where they digest protein, fat and CHO.
27
Distal Intestinal Obstruction Syndrome
- Also known as 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
28
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 915-20% protein) or use RDA
29
Fat Intake in CF
-Fat intake 35-40% of calories, as tolerated
-Helps provide required energy, EFA, 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 pts despite intake and pancreatic enzymes
30
Symptoms of Fat Intolerance
- Increased frequency of stools
- Greasy stools
- Abdominal cramping
31
CHO in CF
- Eventually intake may need to be modified if glucose intolerance develops
- Some pts develop lactose intolerance as well
32
Vitamins in CF
- With pancreatic enzymes, water soluble vitamins usually adequately absorb with daily multivitamin
- Will need high potency supplementation of fat soluble vitamins (A, D, K, E)
33
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, but infants need supplementation 1/4-1/2 tsp/day
- Decreased bone mineralization, low Fe stores, and low magnesium levels have all been described in CF
34
Feeding Strategies for Infants with CF
- Breast feeding with supplements of high-calorie formulas and pancreatic enzymes
- Calorie dense infant formulas 920-27 kcals/oz) with enzymes
- Protein hydrolysate formulas with MCT oil if needed
35
Feeding Strategies for Children and Adults with CF
- Regular mealtimes
- Large portions
- Extra snacks
- Nutrient-dense foods
- Nocturnal enteral feedings with intact or hydrolyzed formulas. Add enzyme powder to feedings or take before or during.
36
TB Symptoms
- Persistent cough for more than 2 weeks
- Weight loss
- Night sweats
- Hemoptysis
- Dyspnea
- Malaise
37
Nutritional Factors that Increase Risk of TB
- Protein-energy malnutrition which affects the immune system
- Micronutrient deficiencies that affect immune function (vitamin D, A, C, iron, zinc)
38
Nutritional Consequences of TB
- Increased expenditure
- Loss of appetite and body weight
- Increase in protein catabolism leading to muscle break down
- Malabsorption causing diarrhea, loss of fluids, electrolytes
39
Nutritional Needs in TB
- Energy: 35-40 kcals/kg of ideal body weight
- Protein: 1.2-1.5 g/kg body weight, or 15% of energy or 75-100 g/day
- Multivitamin-mineral supplement at 100-150% DRI
40
Nutrition Interventions for TB
- Small frequent meals/snacks
- Supplements
- Relationship of meds/meals
- Calorie count
41
Chronic Obstructive Pulmonary Disease (COPD)
Characterized by airway obstruction and is caused by emphysema or chronic bronchitis.
42
Emphysema
Abnormal, permanent enlargement of alveoli, accompanied by destruction of their walls without obvious fibrosis. These pts are thin, often cachectic; older, mild hypoxia, normal hematocrits.
43
Chronic Bronchitis
Chronic, productive cough with inflammation of one or more of the bronchi and secondary changes in lung tissue. These pts are of normal weight; often overweight; hypoxia; high hematocrit.
44
Bronchospasm
Asthma
45
Cor Pumonale
Heart condition characterized by right ventricular enlargement and failure that results from resistance to passage of blood through the lungs.
46
Hypercapnia
Excessive CO2 in the blood which can cause a pt with COPD to be confused and have a headache in the mornings.
47
Nutrient Needs in Stable COPD Pts
- Protein: 1.2-1.7 g/kg (15-20% of kcals) to restore lung and muscle strength and promote immune function.
- Fat: 30-45% of kcals
- CHO: 40-55% of kcals
- Maintain appropriate RQ
- Address other underlying diseases
- Vitamins: intakes should meat DRI
- Smokers may need more vitamin C (+16-32mg)
- Minerals: meet DRis and monitor phosphorus and magnesium in pts at risk for refeeding during aggressive nutrition support
48
Treatments for COPD
- Bronchodilators- theophylline and aminophylline
- Antibiotics- secondary infections
- Respiratory therapy
- Exercise to strengthen muscles
49
MNT in COPD
- GI motility- adequate exercise, fluids and dietary fiber
- Abd bloating- limit foods associate with gas formation
- Fatigue- resting before meals, eating nutrient-dense foods, arrange assistance with shopping and meal preparation
50
MNT in COPD
Suggest that the pt:
- 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
51
MNT in COPD
- Oral supplements
- Nocturnal or supplemental tube feedings
- Specialized pulmonary products generally not necessary
52
Aminoglycosides Food/Drug Interaction
Lowers serum Mg++, may need to replace
53
Prednisone Food/Drug Interaction
Monitor nitrogen, Ca++, serum glucose etc.
54
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
55
Aspiration
Movement of food or fluid into the lungs which can result in pneumonia or even death. Increased risk for infants, toddlers, older adults, persons with oral, upper GI, neurologic, or muscular abnormalities. Many aspirations are "silent" and often involve oropharyngeal secretions.
56
Aspiration Symptoms
- Dyspnea
- Tachycardia
- Wheezing
- Rales
- Anxiety
- Agitation
- Cyanosis
57
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 hypoxia
58
Goals of Treatment of ALI and ARDS
- Improve oxygen delivery and provide hemodynamic support
- Reduce oxygen consumption
- Optimize gas exchange
- Individualize nutrition support
59
Nutrition Assessment in ALI and ARDS
- Indirect calorimetry best tool to determine energy needs in critically ill pts
- In absence of calorimetry, use predictive equations with stress factors
- Avoid overfeeding
- Pts may need high calorie density feedings to achieve fluid balance
60
Spirometer
Gives information on lung volume and the rate at which air can be inhaled and exhaled.
61
Respiratory Quotient (RQ)
- The rate of CO2 expired to the volume of oxygen inspired
| - Excessive amounts of CHOs increase the RQ and the output of CO2, making the work of breathing more difficult
