MNT FOR

PULMONARY
DISORDER

C L E O N A R A YA N U A R D I N I , S . G Z . , M . S C . , R D
PULMONARY SYSTEM
• The electrical impulses generated by the
respiratory center are carried by the phrenic
nerves to the diaphragm and other
respiratory muscles.
• Contraction of diaphragm and other muscles
increases the intrathoracic volume, which
creates negative intrathoracic pressure and
allows air to be sucked in.
• The air traverses through upper and lower
airways (see Figure 34-1, A) and reaches
alveoli (see Figure 34-1, B).
• The alveoli are surrounded by capillaries
where gas exchange takes place (see Figure
34-1, C).
• The large pulmonary blood vessels and the
conducting airways are located in a
welldefined connective tissue compartment—
the pleural cavity.
 PULMONARY SYSTEM
• The airways have 12 types of epithelial cells,
• The primary function of the respiratory system and most cells that line the trachea, bronchi,
is gas exchange. The lungs enable the body and bronchioles have cilia move the
to obtain the oxygen needed to meet its superficial liquid lining layer from deep within
cellular metabolic demands and to remove the lungs, toward the pharynx to enter the
the carbon dioxide (CO2) produced. gastrointestinal tract, thereby playing an
important role as a lung defense mechanism by
Healthy nerves, blood, and lymph are needed clearing bacteria and other foreign bodies.
to supply oxygen and nutrients to all tissues.
• The epithelial surface of the alveoli contains
• The lungs also filter, warm, and humidify macrophages. By the process of phagocytosis,
inspired air these alveolar macrophages engulf inhaled inert
materials and microorganisms and digest them.
• The lungs are an important part of the
• The alveolar cells also secrete surfactant, a
body’s immune defense system, because compound synthesized from proteins and
inspired air is laden with particles and phospholipids that maintains the stability of
microorganisms. Mucus keeps the airways pulmonary tissue by reducing the surface
moist and traps the particles and tension of fluids that coat the lung.
microorganisms from inspired air.
 EFFECT OF MALNUTRITION ON THE PULMONARY SYSTEM
• Malnutrition adversely affects lung structure, elasticity, and function; respiratory muscle mass,
strength, and endurance; lung immune defense mechanisms; and control of breathing.
• Protein and iron deficiencies result in low hemoglobin levels that diminish the oxygen-carrying
capacity of the blood.
• Low levels of calcium, magnesium, phosphorus, and potassium compromise respiratory muscle
function at the cellular level.
• Hypoalbuminemia, contributes to the development of pulmonary edema by decreasing colloid
osmotic pressure, allowing body fluids to move into the interstitial space. Decreased levels of
surfactant contribute to the collapse of alveoli, thereby increasing the work of breathing.
• The supporting connective tissue of the lungs is composed of collagen, which requires ascorbic
acid for its synthesis.
• Normal airway mucus is a substance consisting of water, glycoproteins, and electrolytes,and
thus requires adequate nutritional intake.
EFFECTS OF LUNG
DISEASE ON
NUTRITION STATUS
• Pulmonary disease substantially increases
energy requirements.
• This factor explains the rationale for including
body composition and weight parameters in
nutrition assessment.
• Weight loss from inadequate energy intake is
significantly correlated with a poor prognosis
in persons with pulmonary diseases.
• Malnutrition leading to impaired immunity
places any patient at high risk for developing
respiratory infections.
• Malnourished patients with pulmonary disease
who are hospitalized are likely to have lengthy
stays and are susceptible to increased
morbidity and mortality.
LUNG CANCER

• The primary sites of lung cancer are usually the bronchi, with subsequent metastasis to other
organs
• Lung cancer associated with persistent tobacco smoking for many years, inhaled pollutants may
initiate malignant condition.
• Routine chest radiograph in an asymptomatic smoker.
• Medical treatment: radiation therapy, chemotherapy, surgery
• Smoking cessation  most wellness programs and offer ideal settings for nutrition education
SIGN SYMPTOM
• Dyspnea is the most burdensome cancer symptom, and occurs in 15% to 55% of lung cancer
patients at diagnosis. In addition to the tumor, other factors contribute to the symptom of dyspnea
– factors such as pericardial effusion, anemia, fatigue, depression, anxiety, metastatic involvement of
other organs, aspiration, anorexia-cachexia syndrome, and pleural effusion.
• Progressive weight loss with changes in body composition. Malnutrition impairs the contractility
of the respiratory muscles, affecting endurance and respiratory mechanics. weight loss is associated
with increasing mortality, and weight loss of even 5% indicates a poor prognosis.
• Cough is present in 50% to 75% of lung cancer patients at presentation and occurs most
frequently in squamous cell and small cell carcinoma because of their tendency to involve central
airways (Huhmann and Camporeale, 2012).
• Pain and fatigue are common symptoms associated with lung cancer. The tumor may produce
pleuritic pain because of tumor extension into the pleura, or musculoskeletal type pain because of
extension into the chest wall
• Pulmonary cachexia syndrome affects patients with advanced lung disease and is defined by a
BMI of less than 20 or a weight less than 90% of IBW (Bellini, 2013).
CONSEQUENCES OF
MALNUTRITION
• Patient quality of life (QoL) is an
extremely important outcome
measure for cancer patients, their
carers and families.
• How patients feel, physically and
emotionally, whilst living with cancer
can have an enormous effect on their
recovery, ability to carry out normal
daily functions, as well as their
interpersonal relationships and ability
to work.
The National Comprehensive Cancer Network (NCCN) guidelines include
nutritional assessments, medications, and nonpharmacologic approaches to
achieve the following:
1.Treat the reversible causes of anorexia such as early satiety
2. Evaluate the rate and severity of weight loss
3. Treat the symptoms interfering with food intake: nausea and vomiting, dyspnea,
mucositis, constipation, and pain
4. Assess the use of appetite stimulants like megestrol acetate and Decadron
(corticosteroids)
5. Provide nutritional support (enteral or parenteral)
(Del Ferraro et al, 2012)
MNT FOR LUNG CANCER
Accepted components of oral nutrition therapy
arethe following:
1. Small frequent meals that are high in fat and
protein and low in carbohydrate
2. Provision of adequate calories that meet or
exceed the resting energy expenditure (REE)
3. Rest before meals
4. Meals that require minimal preparation
• Increase consumption of fruits and
vegetables may beneficial
• Providing foods and beverages and
nutritional supplements in the forms
and at the times best tolerated by
the patients is essential
• Administering oral medications with
calorically dense nutritional
supplements is another means of
supplying needed nutrients

5. Oral supplements with the ratio of fat:

carbohydrate of 3:1 that are better tolerated
because the respiratory quotient for
carbohydrates is 1.0 and for fats is only 0.7 and
thus results in decreased work of breathing
(Bellini, 2013)
Certain chemotherapy agents require an
empty stomach to optimise absorption and
therefore healthcare professionals may need
to advise patients to avoid eating one hour
before or up to two hours after taking such
medication
NUTRITION INTERVENTION
• Nutritional interventions can include dietary
advice, oral nutritional supplements
(ONS),enteral tube feeding (ETF) and in some
instances parenteral nutrition (PN)
• Nutritional support can help patients to maintain
weight, improve tolerance to treatment, maximise
outcomes and improve QoL.
• Patients may require nutritional support from the
onset at diagnosis, during treatment and
throughout the whole patient journey, with early
use of oral nutritional supplements (ONS).
• ONS can improve energy intake and reduce weight
loss in cancer
• Nutritional intervention with ONS can also
improve QoL in patients who are malnourished
and may also result in cost savings

• Systematic reviews and NICE Clinical Guidance 32 have demonstrated

ONS clinical efficacy and cost-effectiveness of ONS in the
management of malnutrition, particularly amongst those patients with
a low Body Mass Index (BMI<20kg/m2)
• There is also a low threshold in particular patients undergoing
radiotherapy to progress to ETF if they are unable to meet their
nutritional requirements orally
PNEUMONIA

• An inflammatory condition of the lungs that causes

chest pain, fever, cough, and dyspnea
• Infection of bacteria, viruses or fungi or as a consequence
of aspiration of food, fluid or secretions as saliva
• Infection/ foreign material alveoli inflamed air sacs fill
with fluid or pus cough, fever, chills and labored
breathing
• various kinds of pneumonias, such as community-acquired
pneumonia (viral or bacterial); hospital-acquired
pneumonia; pneumonia in an immune compromised host;
ventilator-associated pneumonia (VAP); and aspiration
pneumonia,
MNT OF PNEUMONIA
• Objective: provide adequate fluids and energy
• Small, frequent meals of nourishing foods
usually are better tolerated, coupled with
proper positioning during eating
• EFA ingestion of alfa linolenic and linoleic
acids protective effects against pneumonia
• As per the 2009 Society of Critical Care Medicine
and American Society for Parenteral and Enteral
Nutrition (SCCM/ASPEN) guidelines, nutritional
interventions for preventing aspiration pneumonia
and managing it when it exists in the patient in the
acute care setting are the following:
• Direct tube feedings into the small bowel rather than
the stomach
• Implement continuous feedings rather than bolus
feedings recommended
• Elevate the head of the patient’s bed to 45 degrees
• Use prokinetic agents
• Minimize use of sedatives
• Optimize oral hygiene
• Use naloxone to improve gut motility (Allen et al,
2013)
RESPIRATORY FAILURE

• RF occurs when the pulmonary system is unable to perform its functions

• Traumatic, surgical, medical
• Acute respiratory distress syndrome is a common complication of critical illness
• Patients requires oxygen provided through a nasal cannula or by mechanical ventilator support
for varying lengths of time and at various level of oxygen
• Hypercatabolism or hypermetabolism may be present
MNT FOR RESPIRATORY FAILURE

Goals:
• meet basic nutritional requirements
• preserve lean body mass
• restore respiratory muscle mass and strength,
• maintain fluid balance
• Improve resistance to infection
• Facilitate weaning from oxygen support and mechanical ventilation by providing energy
subtrate without exceeding the capacity of the respiratory systems to clear CO2
Methods: depend on underlying disease (acutely/chronically ill), ventilator support is necessary
Energy
• Elevated due to hyper-catabolism and hyper-metabolism, sufficient energy must be supplied to prevent the use
of the body’s own reserves of protein and fat
• Energy requirements fluctuate and thus are best determined by continuous individual assessment

Protein
• 1.5-2 g/kg dry BW
• Enterally supplied protein does affect the RQ

Carbohydrate and Fat

• Affecting by underlying organ systems decompensation, patient’s respiratory status,ventilation method used
CHRONIC OBSTRUCTIVE PULMONARY
DISEASE (COPD)
• COPD is now the third most common cause
of death in the world and is predicted to be
the fifth most common cause of disability by
2020 (Burney et al, 2014).
• Patients with COPD suffer from decreased
food intake and malnutrition that causes
respiratory muscle weakness, increased
disability, increased susceptibility to infections,
and hormonal alterations.
 PATHOPHYSIOLOGY COPD

• COPD is a term that encompasses chronic bronchitis and emphysema

• These conditions may coexist in varying degrees and are generally not reversible.
• Patients with primary emphysema suffer from greater dyspnea and cachexia.
• Patients with bronchitis have hypoxia, hypercapnia and complications such as
pulmonary hypertension and right heart failure (Papaioannou et al, 2013).
• COPD exacerbations can be caused by Haemophilus influenzae, Moraxella
catarrhalis, S. pneumonia, rhinovirus, coronavirus, and to a lesser degree, organisms
such as P. aeruginosa, S. aureus, Mycoplasma spp., and Chlamydia pneumoniae.
• Allergies, smoking, congestive heart failure, pulmonary embolism, pneumonia, and
systemic infections are the reason for 20% to 40% of COPD exacerbations
(Nakawah et al, 2013).

• Chronic bronchitis: a long-term condition of COPD in which inflamed

bronchi lead to mucus, cough and difficulty breathing
• Emphysema: a form of long-term lung disease characterized by the
destruction of lung parenchyma with lack of elastic recoil.
• Hypercapnia : increased amount of carbon dioxide
• Although cigarette smoking is considered a
major risk factor for developing COPD, only
about 20% of smokers develop the disease
(Hirayama et al, 2010).
• Osteoporosis in COPD patients not only
predisposes patients to painful vertebral
fractures but also affects lung function by
altering the configuration of the chest wall.
• Frequent acute exacerbations in COPD • Factors that influence the prognosis of COPD
patients increase the severity of chronic system are the severity of disease, genetic
inflammation. This leads to bone loss by predisposition, nutritional status, environmental
inhibiting bone metabolism. Lack of sun exposures, and acute exacerbations.
exposure and physical activity with COPD
leads to a lack of 25-hydroxy vitamin D (25-
OHD), which regulates bone metabolism by
promoting the absorption of calcium (Xiaomei
et al, 2014).
MEDICAL NUTRITION THERAPY
• Malnutrition is a common problem associated
with COPD, with prevalence rates of 30% to 60%
due to the extra energy required by the work of
breathing and frequent and recurrent respiratory
infections.
• Breathing with normal lungs expends 36 to 72
kcal/day; it increases 10-fold in patients with
COPD (Hill et al, 2013).
• Infection with fever increases metabolic rate even
further
• An independent predictor of increased mortality
in COPD patients is low body weight.: Low body
weight is due to poor nutritional intake, an
increased metabolic rate, or both.
• Inadequate food intake and poor appetite are the
primary targets for intervention in patients with
COPD.
• Weight loss in advanced COPD is considered an
independent risk factor for mortality, whereas
weight gain reverses the negative effect of
decreased body weight (Berman, 2011).

• Depletion of protein and vital minerals such as calcium, magnesium, potassium, and phosphorus
contribute to respiratory muscle function impairment.

• In severe malnutrition inadequate electrolyte repletion during aggressive nutrition repletion can
lead to severe metabolic consequences related to refeeding syndrome
MACRONUTRIENTS
• In stable COPD, requirements for water, protein, fat, and carbohydrate are determined by the
underlying lung disease, oxygen therapy, medications, weight status, and any acute fluid fluctuations.
• Attention to the metabolic side effects of malnutrition and the role of individual amino acids is
necessary.
• Determination of a specific patient’s macronutrient needs is made on an individual basis, with close
monitoring of outcomes
• A balanced ratio of protein (15% to 20% of calories) with fat (30% to 45% of calories) and
carbohydrate (40% to 55% of calories) is important to preserve a satisfactory respiratory
quotient (RQ) from substrate metabolism use
• Repletion but not overfeeding is particularly critical in patients with compromised ability to exchange
gases as excess feeding of calories results in CO2 that must be expelled.
• Other concurrent disease processes such as cardiovascular or renal disease, cancer, or diabetes
affect the total amounts, ratios, and kinds of protein, fat, and carbohydrate prescribed.
ENERGY
• Meeting energy needs can be difficult.
• For patients participating in pulmonary rehabilitation programs, energy
requirements depend on the intensity and frequency of exercise therapy and can
be increased or decreased.
• Energy balance and nitrogen balance are intertwined. Consequently, maintaining
optimal energy balance is essential to preserving visceral and somatic proteins.
• Caloric needs may vary significantly from one person to the next and even in the
same individual over time
FAT
• In theory, intake of long-chain omega-3
PUFAs, which reduces inflammation,
should improve the efficacy of COPD
treatments.
• PUFA supplementation is beneficial in
COPD, but various factors such as
supplement adherence, comorbidities, and
duration of the supplementation play vital
roles(Fulton et al, 2012).
• Dietary supplementation of DHA and AA
has been shown to delay and reduce risk
of upper respiratory infections and
asthma, with lowering the incidence of
bronchiolitis during the first year of lif.
Data from various studies have shown the
positive impact of long-chain PUFAs in
initiating and providing resolution of
inflammation in respiratory diseases (Shek
et al, 2012).
PROTEIN
• Sufficient protein of 1.2 to 1.5
g/kg of dry body weight is
necessary to maintain or
restore lung and muscle
strength, as well as to promote
immune function.
VITAMINS AND MINERALS
• Vitamin and mineral requirements for individuals
with stable COPD depend on the underlying
pathologic conditions of the lung, other
concurrent diseases, medical treatments, weight
status, and bone mineral density.
• For people continuing to smoke tobacco,
additional vitamin C is necessary
• The role of minerals such as magnesium and
calcium in muscle contraction and relaxation may
be important for people with COPD.
• Intakes at least equivalent to the dietary
reference intake (DRI) should be provided.
• Depending on bone mineral density test results,
coupled with food intake history and
glucocorticoid medications use, additional
vitamins D and K also may be necessary
• Patients with cor pulmonale and subsequent fluid
retention require sodium and fluid restriction.
Depending on the diuretics prescribed, increased
potassium supplementation may be required. And
other water soluble vitamins, particularly thiamin,
may need to be supplemented.
• Patients are recommended to drink
adequate fluids and stay hydrated to help
sputum consistency and easier
expectoration.
• The Parenteral and Enteral Nutrition
Group (PENG) recommends a fluid intake
of 35 ml/kg body weight daily for adults 18
to 60 years and 30 ml of fluid/kg body
daily for adults over 60 years (PENG,
2011).
• COPD patients report difficulties with
eating because of low appetite, increased
breathlessness when eating, difficulty
shopping and preparing meals, dry mouth,
early satiety and bloating, anxiety and
depression, and fatigue.
• In addition to the above, inefficient and
overworking respiratory muscles lead to
increased nutritional requirements
PATIENTS IN THE ADVANCED STAGE OF
COPD
• Patients with advanced COPD are
undernourished and in a state of
pulmonary cachexia.
• Osteoporosis exists as a significant problem
in 24% to 69% of patients with advanced
COPD (Evans and Morgan, 2014) because of
immobility, which also leads to
deconditioning and dyspnea.
• Smoking, low BMI, low skeletal muscle mass,
and corticosteroid usage can lead to bone
loss along with low serum vitamin D levels
(Evans and Morgan, 2014)
TUBERCULOSIS

• Mycobacterium tuberculosis: an intracellular

bacterial parasite, has a slow rate of growth, is an • As soon as the diagnosis is established, treatment
obligate aerobe, and induces a granulomatous with four anti-TB medications - INH, rifampin,
response in the tissues of a normal host. pyrazinamide and thambutol - is started.
• When an infectious TB patient coughs, the cough • These medications are continued for 2 months,
droplets contain tuberculous bacilli. Small and then only rifampin and INH are continued for
particles penetrate deep into the lungs. Each of 4 more months.
these tiny droplets may carry 1 to 5 bacilli, which
are enough to establish infection. This is the
reason why cases of active TB must be isolated till
they become noninfectious.
• Chest radiograph, chronic cough, prolonged fever,
night sweats, anorexia and weight loss.
MEDICAL NUTRITION THERAPY
• Malnutrition is common in patients with
pulmonary TB, and nutritional supplementation is
necessary.
• Markers of protein nutritional status are low
levels of the inflammatory proteins,
anthropometric indices, and the micronutrient
status of TB patients (Miyata et al, 2013).
• TB leads to or worsens any preexisting condition
of malnutrition and increases catabolism.
• Active TB is associated with weight loss, cachexia,
and low serum concentration of leptin.
• Malnutrition increases the risk of infection and
early progression of infection to produce active
TB.
• In the long term, malnutrition increases the risk
of reactivation of the TB disease.
• Malnutrition also can lower the effectiveness of
the anti-TB drug regime, which patients have to
be on for several months.
• The efficacy of Bacillus Calmette-Guerin (BCG)
vaccine can also be impaired by malnutrition.
Energy
• Current energy recommendations are
those for undernourished and catabolic
patients, 35 to 40 kcal/kg of ideal body
weight.
• For patients with any concomitant
infections such as HIV, energy
requirements increase by 20% to 30% to
maintain body weight.
Protein
• Protein is vital in preventing muscle tissue
wastage and an intake of 15% of energy
needs or 1.2 to 1.5 g/kg ideal body weight,
approximately 75 to 100 g per day, is
recommended.
Vitamins and Minerals
• provides 50% to 150% of the RDA is helpful
• Nutrients such as vitamin A, the B vitamins,
vitamins C and E, zinc, and selenium are
usually deficient in TB
• Vitamin D deficiencies are common with TB
and result because of an insufficient vitamin
D intake and limited exposure to
sunlightatients
• Isoniazid is an antagonist of vitamin B6
(pyridoxine) and is frequently used in TB
treatment nutritional depletion of vitamin
B6 peripheral neuropathy
• Iron deficiency anemia is the most important
contributor in the development of anemia in
TB patients (Isanaka et al, 2012). Evidence
indicates that excess iron supplementation
may be dangerous to TB patients, and the
use of iron therapy is not universally
recommended. However, if iron studies show
iron deficiency, iron therapy is then initiated