MEDICAL NUTRITION THERAPY

FOR PULMONARY DISEASE

DEPARTEMEN GIZI
FAKULTAS KEDOKTERAN
USU
Pulmonary system disorders may be categorized as .
Primary:
Tuberculosis (TB),
Bronchial asthma
Cancer of the lung
Secondary:
Associated with cardiovascular disease
Obesity
HIV disease
Sickle disease
Scoliosis.
Acute or chronic
Acute conditions :
aspiration pneumonia,
airway obstruction from foods like peanuts
allergic anaphylaxis from consumption of shellfish

Chronic condition: cystic fibrosis (CF) & Lung cancer.

 MNT in Pulmonary Disease

Integral components of care for patient with PD are

Individualized nutrition assessment
Diagnosis
Intervention
Routine monitoring & evaluation
Concomitant assessment of the CV,renal, neurologic, and
hematologic systems is important diseases often
produce complications affecting pulmonary anatomy,
physiologic findings, and biochemistry.

Nutrition assessment precedes any nutrition intervention or

medical treatment, unless the treatment is emergent.
 Pulmonary aspiration involves the movement of food
or fluid into the lungs pneumonia (+) or
even death.
Infants and toddlers are increased risk for aspiration
Also older adults with oral, gastrointestinal,
neurologic, or muscular abnormalities .
Close attention must be given to people receiving
enteral tube feeding.
Primary reason for aspiration pneumonia is excessive
lung secretions so pulmonary treatment and
suctioning are critical to preventing aspiration.
 Asthma
A disease of bronchial hyperresponsiveness & airway inflammation.
As a result from complex interactions among genetic, immuno logic, and
environmental factors.
Characterized by.
Increase mucus secretion obstruct the airways
Inflammation & swelling
Smooth muscle tightening smaller airways.

MNT.
Food & individual nutrients have possible roles in the treatment of asthma.
Soy, -3 fatty acids and -6 fatty acids (decreasing the production of
bronchoconstrictive leukotrienes)
Antioxidant nutrients (protecting the airway tissues from oxidative stress)
Magnesium a smooth-muscle relaxants & antiinflammatory agent
Caffeine bronchodilator.
 Nutrition assessment and therapy must take into acount routinely
prescribed medications i.e corticosteroid can causes bone
demineralization bone density test (+).
Nutritional therapy should include individual evaluation for environmental
or food triggers and strategies for their avoidance if necessary.
Have to provide:
optimal energy and balance of nutrients, proper ratio of -3 and -6
fatty acids and phytonutrients
Correction of diagnosed energy & nutrient deficiencies or excesses,
Carefull attention to medication - food nutrient interactions
Frequent monitoring to maintain healthy pulmonary status
Education of the patient, family & community.
 Chronic Obstructive Pulmonary Disease (COPD)

COPD is a characterized by slow, progressive obstruction of the airways.

Subsidized into two categories:
Emphysema (type I) , which is characterized by abnormal,
permanentenlargement and destruction of the alveoli.
Chronic bronchitis (typeII) ,in which there is a productive cough with
inflammation of the bronchi and other lung changes
Causative factors are
Tobacco smoking or primary causative
Continual contact with second-hand smoke factors
Environmental air pollution ( including cooking in a confined, unventilated
space).
Genetic susceptibility.
Patients with emphysema are thin and often cachectic
Patients with chronic bronchitis are of normal weight, and indeed, are often
overweight.
MNT.
Primary goals of nutrition care are.
To facilitate nutritional well being.
Maintain an appropriate ratio of lean body mass to adipose tissue.
Correct fluid imbalance
Manage drug-nutrient interactions
Prevent osteoporosis

Energy.
Meeting energy needs can be difficult.
Energy requirements depend on the intensity and frequency of exercise
therapy.
Remember: energy balance and nitrogen balance are intertwined.
Maintaining optimal energy balance is essential to preserving visveral and
somatic proteins.
When enrgy equations are use for prediction of needs, increases for
physiologic stress must be included.
Caloric needs may vary significantly from one person to the other.
Macronutrient.
In stable COPD , requirements for water, protein, fat, and
carbohydrate are determined by the
underlying lung disease,
oxygen therapy,
medications,
weight status,
acute fluid fluctuations.
Attention:
metabolic side effects of malnutrition
The role of individual amino acids
Determination of a specific patients macronutrient needs is
made on an individual basis,
 Sufficient protein of 1.2 1.7 g/kg of dry BW is necessary to
maintain or restore lung and muscle strength , as well as to
promote immune function.
A balance ratio of macronutrient is important to preserve a
satisfactory RQ from substrate metabolism use.

Vitamin & Minerals.

Depend on the underlying pathologic conditions of
the lung
Other concurrent diseases
Medical treatments
Weight status
Bone mineral density.
 For people continuing to smoke tobacco need addi
tional Vit.C
Research : one pack of cigarettes /day ,require 16 mg more
ascorbate per day, two packs 32 mg more than RDA.
Additional Vit.D and K may be necessary based on
Bone mineral density test results
Food intake history
Glucocorticoid medications use.
Patients with cor pulmonale and subsequent fluid retention
require sodium & fluid restriction.
Diuretics (+) increased dietary intake of Potassium.
Feeding strategies.
Interdisciplinary team (+)
A modified oral diet is usually preferred.
Adequate exercise, fluids, and easily chewed dietary fiber enhance
gastrointestinal motility
Some suggestions are:
Resting before meals
Eating small portions of nutrient-dense foods
Planning medications and breathing treatments around mealtimes
For many patients using oxygen at mealtimes:
Eating slowly
Chewing foods well
Engaging in social interaction

To prevent aspiration caution must be given to proper sequencing of

breathing with swallowing as well as to proper sitting posture during
eating
Enteral tube feeding can be used to increase total caloric & nutrient
intake
 CYSTIC FIBROSIS (CF)
CF is a complex multisystem disorder that is ingerited in an
auto somal-recessive fashion.
CF wa once thought to be only a pediatric disease, but the
number of people surviving to or being diagnosed at 18 years
or older is 42%.
The clinical features are dominated by involvement of the
respiratory tract, sweat & salivary glands, intestine, pancreas,
liver, and reproductive tract.
Pulmonary complications (+)
Infection with Staphylococcus aureus & Pseudomonas aeru
ginosa is typical.
 Medical Nutrition Therapy
The goals of nutrition care in CF are
To control maldigestion and malabsorption
Provide adequate nutrients
Promote optimal growth or maintain weight for height.
Support pulmonary function
Prevent nutritional deficiencies.
Macronutient.
Energy needs vary widely from individual to individual.
Patients with CF should not be encouraged to decrease their activity
levels, but rather to increase their energy intake instead
Dietary protein levels are increases in CF as a result of malabsorption,
but if energy needs are met, the protein intake also enough.
 Fat intake should provide 35 40% or more of total calories.
Dietary fat helps to provide
The required energy
EFAs (linoleic acid and linolenic acid)
Fat soluble vitamins
Fat limits the volume of food required to meet energy demands
Improves the palatability of the diet.
At-risk patients need to be encouraged to include sources of EFAs
(canola, soybean, corn oil,fish) as part of daily fat intake.
As the disease progresses, changes in carbohydrate intake
may be necessary.
Lactose intolerance and pancreatic endocrine involvement
may require carbohydrate adjusments.
Vitamins & Minerals.
With pancreatic enzyme replacement, the water soluble
vitamins are adequately absorbed, but fat soluble vitamins
remain inadequately absorbed.
Low serum concentrations of vit.A despite increased hepatic
stores , suggesting impaired mobilization and transport of the
vitamin from the liver.
Decreased level of vit.D (+) decreased bone mineral
content.
Low vit.E hemolytic anemia & abnormal neurologic.
CF may be risk of vit.K deficiency secondary to long-term use
of antibiotics or liver disease or malabsorption.
Thus vitamin regimens should be adjusted based on routine
serum monitoring of the individual.
 Sodium requirements are increased in CF because of incre ased
losses in sweat.
Supplemental salt is required , especially during periods of
fever, hot weather, or physical exertion.
Other minerals are not routinely supplemented, although
mineral status should be evaluated on an individual basis.
Low iron stores and low magnesium levels have been des
cribed in CF.plasma zinc levels may be low in cases of modera
te to severe malnutrition.
Feeding strategies.
Intake can be enhanced by regular and enjoyable mealtimes,
larger food portions at meals, extra snacks , and foods selected
for high-nutrient density.
Feeding tube is an alternative if the oral tube is unable to meet
nutritional needs.
 LUNG CANCER
The primary sites of lung ca are usually the bronchi.
Is often associated with persistent tobacco smoking and
other inhaled pollutants may initiate the malignant condition.

Medical Nutrition Therapy.

High dose carotene supplements may have a negative
effect,whereas increased consumption of fruits & vegetables
may be beneficial.
Because eating may become unpleasant activity, providing
foods, beverages , and nutritional supplements in the forms
and at the times best tolerated by the patient is essential.
 PNEUMONIA
Pneumonia usually occurs as an infection from bacteria,
viruses, or fungi, or as a consequence of aspiration of food,
fluid, or secretion such as saliva.

Medical Nutrition Therapy.

The role of vit.A in treating Pn in children yielded conflicting
results .
EFAs in adults have a protective effect against Pn (their role in
inflammation & immunity), especially linolenic & linoleic acids.
Pn (+) the goals of nutrition care are to provide
adequate fluids and energy.
Small,frequent meals of nourishing foods usually are better
tolerated, coupled with proper positioning during eating.
 RESPIRATORY FAILURE (RF)
Occurs when the pulmonary system is unable to perform its
function.
The causes may be:
Traumatic
Surgical
Medical.
RF patient needs oxygen provided through nasal canula or by
mechanical ventilator support.
Medical Nutrition Therapy.
Nutrition needs depend on
The underlying disease process
Prior nutrition status
Age
The goal of nutrition care are
To meet basic nutritional requirements
Preserve lean body mass
Restore respiratory muscle mass & strengh
Maintain fluid balance
Improve resistance to infection
Facilitate weaning from oxygen support .
Energy.
Hyoercatabolism + hypermetabolism (+) energy needs are
elevated.
Sufficient energy must be supplied to prevent the use of the bodys own
reserves of protein & fat.

Macronutrient.
The basic requirement for CH and Fat are influenced by
The underlying organ system decompensation
Respiratory status
Ventilation methods used.
 Protein is calculated 1.5-2 g/kg of dry body weight.
Nonprotein calories are evenly divided between fat and CH.
Daily monitoring of intake is crucial.
Water requirements based on the
Method of oxygen delivery
Environmental factors
Underlying disease
Medications.

Vitamins & Minerals.

Exact requirements for spesific vitamins & minerals in RF are
unknown.
The intake of vitamins & minerals necessary for
Anabolism
Wound healing
Immunity
Those with antioxidant functions may need to be increased.
 Minerals that function as electrolytes need to be monitored
due to
Fluid imbalances
Occurence of respiratory acidosis or alkalosis.
As a side effect of medications: potassium, calcium, and magnesium
may be lost inthe urine.

Feeding strategies.
Small portions and favorite foods enhance oral food intake.
Consumption must be monitored to
Maintain appropriate calorie levels
Suitable ratio of protein, fat, and carbohydrate.
Intubated patients usually require enteral tube feedings or
parenteral feedings.
 TUBERCULOSIS (TB)
Is a bacterial disease caused by mycobacteria, specifically
M.tuberculosis, M.bovis, or M.africanum.

Medical Nutrition Therapy.

Chronic infection need higher calorie intakes & fluids.
Because Isoniazide absorption is reduced by food, it should be
administrated 1 hour before or 2 hours after meals.
It depletes pyridoxine (vit.B6) and interferes with vit.D
metabolism, which in turn can decrease absorption of calcium
and phosphorus.
So, patients require increased vit.B6 and D, and minerals from
meals or supplements .