How to nutritionally manage a pulmonary disease patient

1. How to nutritionally manage a pulmonary disease patient • By • Sherouk Hassieb El Batrawy • Lecturer of chest diseases • Ain Shams University

2. Introduction Nutrients are chemical compounds in food that are absorbed and used to promote health. They are generally divided into: • 1.     Macronutrients: they constitute the bulk of the diet and supply energy as well as essential nutrients needed for growth, maintenance, and activity. They include CHO, fats, proteins, macro minerals (sodium, chloride, potassium, calcium, magnesium, and phosphorous), and water. • 2.     Micronutrients include vitamins and trace elements. • 3.  Other dietary substances:which include food additives and fiber.

3. Malnutrition is the imbalance between the body needs and the intake of nutrients, which can lead to syndromes of deficiency, dependency, toxicity, or obesity. It includes: -Under nutrition: nutrients are under supplied -Over nutrition: nutrients are over supplied. Protein energy malnutrition is a term used widely to cover a spectrum of clinical conditions in both adults and children. It is a deficiency syndrome caused by the inadequate intake of macronutrients. It has the following causes:

4. The nutritional and metabolic changes which occur in critical illness are driven by any combination of. -lack of nutrient intake ( starvation), -The endocrine mediator response to the stress of critical illness,and. -Physiological insult to the gastrointestinal tract. The metabolic response to critical illness is typified by catabolism, protein loss, and immunosupression.

5. It has three forms • 1.     Dry form (marasmus): Results from near starvation with deficiency of protein and non-protein nutrients. • 2.     Wet form (kwashiorkor):Results from more marked protein deficiency than energy deficiency • 3.     Combined form (marasmic kwashiorkor):The patient has edema but more body fat than those with marasmus. In adults, less than eighty percent of expected weight for height or the presence of nutritional edema represent severe malnutrition.

6. N.B.: Cachexia: is the severe emaciation and wasting seen in patients with advanced cancer, AIDS, and other chronic diseases. Superficially, it resembles marasmus, and inadequate food intake is certainly a factor but unlike marasmus where protein catabolism is unchanged and the net loss of tissue protein is the result of reduced replacement, in cachexia there is increase in both protein synthesis and catabolism leading not only to a net increase in protein breakdown, but also to an increased energy consumption

7. Malnutrition in the hospital population • One third of patients admitted to hospital are affected by moderate to severe nutrition. • Once admitted further deterioration due to factors such as poor appetite, concurrent ill health ,inadequate intake, special feeding difficulties, and even kept on ‘nil by mouth’ for investigations • The malnourished patient is often apathetic and withdrawn which is often mistaken for depression

8. In Egypt, Mobasher et al., 1997, found 100% of COPD in patients in respiratory failure to have malnutrition of the marasmic kwashiorkor type. • Malnutrition in patients with COPD is associated with an impaired pulmonary function status, reduced diaphragmatic mass, lower exercise capacity, and higher mortality rate when compared to adequately nourished individuals with COPD • Since nutritional support can increase body weight and physiologic function in COPDIt is thereby considered as a useful non-pharmacological line of therapy

9. Indeed, there is a viscous circle between impairment and malnutrition in COPD: COPD Difficulty consuming food Increased metabolic rate worsening worsening Chronic inadequate intake Increased caloric needs Decreased muscle strength Impaired aerobic capacity Malnutrition ( Kwiatkowski, et al. 1999)

10. Some studies have considered nutritional support an additional metabolic and ventilatory stress on the respiratory system however others demonstrated the disturbed energy balance in weight losing COPD patients hence challenging the previous approach and have also shown that nutritional abnormalities in patients with COPD relate to altered regulation of substrate metabolism caused by changes in anabolic and catabolic stimuli.

11. Nutritional assessment Which patients should be assessed? • Patients presenting with clinical evidence of malnutrition e.g. marasmus, or hypoalbuminemia • Patients with chronic disease. • Patients with acute conditions associated with high catabolic rates e.g sepsis, trauma, burns. • Geriatric patients. • Nutritional failure:when the patient’s nutrient intake falls short of his requirements with insidious onset of signs, symptoms and biochemical findings of malnutrition.

12. N.B.: Subjective global assessment score: It scores the following six features based on history and examination: 1.weight change: loss in past 6 months, past 2 weeks, 2. Dietary intake, 3.GIT symptoms for more than 2 weeks, 4. Functional capacity, 5.stress,and 6.physical signs: loss of SC fat over triceps,wasted deltoid,temporals, fluid retention,&mucosal lesions.

13. Nutritional risk score

14. Interpretation of this score

15. How can nutritional status be assessed in current practice? 1- history and physical examination. 2-anthropometric measurements: -weight and related formulas;e.g % of usual weight -mid –arm circumference -triceps skin fold thickness -mid-arm muscle circumference=MAC-(TSFX3.14) *Results are then compared to percentiles or as a percent of standard

16. 3- biological tests: -plasma proteins: albumin (half life 18-21 days) transferrin( half life 8-12 days) thyroxin binding prealbumin(half life 2 days) retinol binding protein(half life 12 hours) -urinary tests: creatinine height index urinary urea nitrogen(for nitrogen balance) -immune functions: total lymphocytic count)

17. STEPS FOR NUTRITIONAL REGIMEN 1- Determine the basal energy expenditure. 2- Determine the total energy requirements 3- Determine the protein requirement. 4- Determine the energy substrate distribution. 5- Convert requirements into a prescription. 6- Add micronutrients and electrolytes. 7- Estimate the rate of administration.

18. Energy requirements Different ways for estimation: Direct measurement: calorimetry Indirect measurement: 1- simple nomograms : 25 – 35 kcal/kg BW/d 2- Harris Benedict equation: Male=66.5+13.7 x weight( kg)+5 x height(cm)-6.8 x age(years). Female= 655+9.6 x weight (kg) +1.7 x height(cm)-4.7 x age(years)

19. Carbohydrates and proteins have an energy yield of approximately 4 Kcal/g while fats yield about 9 Kcal/g.

20. Planning the nutritional regimen • The nutrient intake should be within an appropriate range. • Any variation within this range should be performed stepwise until the therapeutic goal or the range limit is reached • insulin of 1 IU/10g glucose in malnourished minimally stressed patients up to 1 IU / 5gm glucose in severely stressed patient

21. 4.several anabolic agents are effective in improving the efficacy of conventional nutritional regimens. 5. The recommended daily allowances for vitamins and minerals esp. Zn since high intestinal loss 6. Water supply should be planned strictly according to patient need. Safest way is to fill a bag with the planned nutrient load at the highest concentration. This results in the possibility of adjusting fluid load without changing the nutrient program .

22. clinical settings where enteral nutrition should be part of routine care: -Protein calorie malnutrition (more than 10 percent loss of usual weight or serum albumin less than 3.5 gm/dl) with inadequate oral intake of nutrients for the previous five days. -Normal nutritional status with less than 50 percent of required nutrient intake orally for the previous seven to ten days. - Severe dysphagia

23. Complications of enteral nutrition: • Tube insertion: misplacement, and esophageal problems (inflammations, erosions, stricture),Regurgitation and aspiration,Sinusitis. • Gastrointestinal: Nausea and vomiting, Diarrhea and constipation,Abdominal pain and distension. • Metabolic: Hyperglycemia, Hypoglycemia, Low circulatory levels of potassium, phosphorous, zinc, sodium, and copper,Low red cell folate. • Cardiac failure. • Elevated transaminases,Hypoprothrombinemia,Deficiency of essential fatty acids. • Over hydration. • Aspiration pneumonia,Contaminated formula and equipment. • Psychosensory complications:  Of the taste of food.

24. clinical settings where parenteral nutrition should be part of routine care: .Patients with inability to absorb nutrients by gastrointestinal tract. .Patients undergoing high dose chemotherapy, irradiation, and bone marrow transplant. . Moderate to severe pancreatitis. .Severe malnutrition in the face of non-functioning gastrointestinal tract. .Severe cases .Malnutrition when the gastrointestinal tract is not usable within five to seven days. .Major full thickness burns .Massive small bowl resection in combination with administration of total parentral nutrition (TPN) .Low output entero-cutaneous fistula.

25. TPN is maintained with these specific instructions: - Check vital signs every 4 – 6 hours. - Record body weight daily. -Record volume of fluid intake and output on PN flow sheet. -Perform urine spot test for glucose and ketones every 8 hours. -Change intravenous tubing daily   Change central line dressing every 48 hours -Notify if the temperature raises more than 39° c or 2+ urine glucose. -Daily electrolytes and BUN. Liver enzymes and bilirubin every four days.

26. Complications of TPN: • Catheter related: e.g sepsis, pneumothorax, arterial puncture, brachial plexus injury, thrombosis, …etc • Metabolic complications: e.g hyperglycemia, hypoglycemia, … etc

27. Special problems and requirements • ARDS:- entral as early as possible,1000-1300 calories preferentially as glucose for short term management, after 4-5 days 80 –90 % should be glucose and 10 –20 % as fat together with aa and insulin. • Acute renal failure: continuous renal replacement therapy +conventional nutritional approach.

28. 3.acute liver failure: calorie load towards the lower range, 60% as glucose, 30 – 50 gm aa of branched chain, aromatic, and sulfated aa level, also put in mind they are intolerant to water and sodium. 4.repleting pulmonary failure patients: non protein calories of 35 – 45 kcal/kg/day, and proteins of 1.5 – 2.0 gm/ kg/ day. 5. Maintenance of pulmonary failure patients: 25- 35 kcal /kg/ day +1-1.5 gm/kg/day proteins . 6. Heart failure: BEE X 2 +proteins of 1.2 –1.5 gm/kg/d

29. Recommendations • Nutritional assessment should be systematically performed to detect malnutrition and initiate nutritional support early in the acute illness, which may have a beneficial effect on weaning off the ventilatory support. • Nutritional support should be given as energy dense supplements in quantities well divided during the day to avoid dense metabolic and ventilatory efforts resulting from a high caloric load. • Feeding practices should bemarkedly different in well –nourished and malnourished patients with respiratory failure. • Nutritional therapy should be directed towards replacing deficits in addition to conserving body protein stores.

30. Thank You