NUTRITIONAL MANAGEMENT OF follows intensive therapy for respiratory

PULMONARY DISEASE difficulties in the neonatal period

Lec by: Dr. R.C. Laygo
_______________________________________ Assessment:
 Linear growth
Inadequate energy intake:  Dietary intake
 Weight loss-poor prognosis  GER
 Malnutrition-impaired immunity  Chronic hypoxia
 Length of hospital stay- ↑ morbidity,  Emotional deprivation
mortality
Goals of nutritional care:
Adverse Effects of Lung Diseases on Nutritional  Adequate nutrient intake
Status:  Promote linear growth
 Increase energy expenditure  Develop age appropriate feeding skills
1. ↑ work of breathing  Maintain fluid balance
2. chronic infection
3. medical treatments Energy
(bronchodilator, chest physical Resting Energy Expenditure
therapy)  25-50% greater than that in age matched
 decrease intake controls
1. fluid resuscitation Energy needs vary:
2. shortness of breath  Acute phase 50-85 kcal/kg daily
3. ↓ O2 saturation when eating  Convalescent phase 120-130 kcal/kg or
4. anorexia due to chronic disease more daily
5. GI distress & vomiting
 Additional limitations Macronutrients
1. difficulty preparing food due to  CHON should provide 7% or more of
fatigue total calories
2. lack of financial resources  Additional fat or CHO-made after
3. impaired feeding skills (infants formula has been concentrated to 24
& children) kcal/oz
4. altered metabolism
Maintenance of fluid balance
Herbal remedies:  Fluid restriction
 Cough suppressants  Na restriction
1. volatile oil of eucalyptus  Long term treatment with diuretics
2. peppermint teas
3. lagundi Vitamins & minerals
 expectorants  Vit. ACEK
1. anise  Inositol
2. fennel  FFA
3. thyme
 Selenium
Integral components of Care for patients with
L-glunolactone oxidase-enzyme for Vit C
pulmonary system disease
metabolism
 nutritional assessment
 intervention Important for:
 counseling Hydroxylation of proline→hydroxyproline,
lysine→hydroxylysine for the cross linkage of
Impact of Malnutrition collagen
 ↓ vital capacity (lung volume)
 ↓ minute ventilation (volume Feeding Strategies
exhaled/minute) To meet energy needs:
 ↓ efficiency of ventilation  Calorically dense formulas
 ↑ compliance (dispensability)  Small, frequent feedings
 ↑ elasticity  Use of soft nipple
 ↑ surfactant  NGT or gastrostomy tube feedings
(dipalmitoylphosphatidylcholine) GER
 Thickened feedings
Pulmonary edema (½ to 1 tbsp of infant cereal is
-↓ O2 transport, respiratory muscle strength, added per ounce of formula)
energy substrate in the cell, ventilatory drive  Upright positioning
with hypoxia, immune function
 Medications: antacids, H2 receptor
antagonists
Bronchopulmonary dysplasia-chronic lung
disorder seen in early infancy and usually
Cystic Fibrosis
  inherited autosomal recessive disorder
 Epithelial cells and exocrine glands
secrete abnormal mucus (thick)
 Affects respiratory tract, sweat, salivary,
intestine, pancreas, liver, reproductive
tract
Diagnosis
 Neonatal screening provides
opportunity to prevent
 malnutrition in CF patients
 sweat test (Na & Cl >60 mEq/L)
 chronic lung disease
 failure to thrive
 malabsorption
 family history
Nutritional Assessment
List of important assessment points
Significant findings:
 recent weight loss or <90% BW
 Is weight fluid or adipose or LBM?
 Indirect calorimetry
 Edema lowers total protein & albumin
Anthropometry
 Weight
 Height (≥ 2 yo), length (< 2 yo)
 Head circumference
 Mid-arm circumference
 Triceps skinfold thickness
Nutritional Assessment
 Dietary intake
 3 D fat balance
 Anticipatory dietary guidance
Lab studies
 CBC
 Serum or plasma retinol
 Serum or plasma alpha tocopherol
 Albumin
 Electrolytes & acid base status
Nutritional Problem in CF
 Pancreatic enzyme insufficiency
 Malabsorption
1. ↓ HCO3- secretion
2. ↓ bile acid reabsorption
3. excessive mucus
Symptoms of CF malabsorption
 bulky foul-smelling stools
 cramping
 obstruction
 rectal prolapse
 liver damage
 other problems: impaired
tolerance
Nutritional Care Goals
 control malabsorption
 provide adequate nutrients for growth
Common treatment
 pancreatic enzyme replacement
 adjust macronutrient for symptoms
 nutrients for growth
 meconium ileus equivalent: intestinal
obstruction (enzyme, fiber, fluids,
exercise, stool softeners)
Nutrient Needs
Vitamins
 water soluble vitamins need not be ↑
(exception may be B12)
 fat soluble (may need supplement)
 Na-infants need ⅛ to ¼ tsp/day added
salt
Medical Nutrition Therapy
↑ energy intake
 Serving size
 Snacks
 ↑ calorie foods
 Supplements
 Night gastrostomy tube feeding with
enzyme
 TPN only when GI not usable, or in
advanced CF (monitor risks of sepsis)
COPD-obstruction of airways
 Bronchospasm-asthma
 Overproduction of mucus-bronchitis
 Destruction of elastin-emphysema
 Obstruction-bronchoectasis
 Right sided heart failure-cor pulmonale
Emphysema Chronic Bronchitis
Thin, cachetic, older Normal weight (often overweight)
Hypoxemia-mild Hypoxemia-prominent
Normal Hct Increased Hct
Cor pulmonale-late Cor pulmonale-early
Nutritional Care in Chronic Pulmonary Disease
Goals of Nutritional Therapy
 Maintain acceptable weight for height
 Maintain fluid and acid base balance
 Manage drug nutrient interaction
Nutritional Status
↑ Requirement from maldigestion,
malabsorption
Complications: cough
Retarded growth
GI distress
Anorexia during infection
Altered smell
Nutritional Requirements
Energy
 1.0-1.2 maintenance
glucose  1.4-1.6 repletion
Macronutrient mix
 Do not overfeed!
 RQ=CO2/O2 CHO=1 fat=0.7
 Mixed diet=0.87
Omega 3 FA
 protect smokers from COPD
 anti-inflammatory
 Vit C supplement for smokers
 16-30 mg/day
 RDA-75mg/day
Treatment
 Bronchodilator-theophylline &
aminophylline
 Antibiotics-secondary infection
 Respiratory therapy
 Exercise to strengthen muscles
Categories of Medical Nutrition Therapy
 Routine care
 Anticipatory guidance: 90% IBW
 Supportive intervention: 85-90% IBW
 Resuscitative/palliative: ↓ 75% IBW
 Rehabilitative Care: consistently ↓ 85%
IBW
Medical Nutrient Therapy
 Monitor side effects of food Drug
interaction
 Aminoglycosides ↓ serum Mg++ (need
to replace)
 Prednisone-monitor Nitrogen, Ca++,
serum glucose, etc.
 Positive end expiratory pressure (PEEP)
Nutritional balance important to obtain
 Muscle strength
 Albumin levels
 RQ
 PO4 depletion corrected
Nutritional Care for PTB
Goals: maintain weight
Restore Calcium levels in serum
Replace losses from lung bleed
Promote healing of pulmonary cavities
Counteract side effects of Drug
Prevent dehydration
Summary
Pulmonary
Effect of-nutrition on lungs
Lung status on nutrition
High Metabolic Rate
Will need-extra kcal
-less from carbohydrates than
usual

Cellular damage
 Causes oxidative stress
 Excessive accumulation of O2 free
radicals (superoxide anions, H2O2,
hydroxyl radicals, singlet molecular O2)
 Cellular injury may lead to SIRS
 Mixed results of trials with antioxidants

Oxidative Stress & Critical Illness

 Mounting evidence exists that oxidative
stress plays a pivotal role in critical
illness
 ↓ antioxidant defenses

Gluthathione—made up of cysteine, glysine,

glutamate

Nutritional Care in Respiratory Failure

Goal of Nutritional therapy
 Meet energy & nutrient requirement
 Preserve LBM
 Maintain fluid & acid base balance
 Provide nutritional substrate that will
not ↑ CO2

Respiratory Failure
 Patient on ventilation
 Benefits from giving antioxidant
 Lab values
pCO2 >50mmHg (35-45 mmHg)
pO2 <60mmHg (80-100mmHg)
pH <7.30 (7.35-7.45)
HCO3- (22-26 mEq/L)
O2 saturation >95% (>95%)

Respiratory Weaning
Information monitored
 Concentration of inspired O2 (FiO2)