NUTRITION AND RESPIRATORY PROBLEM

HARUN ALRASYID
FAC.OF MEDICINE
USU-MEDAN
“BETTER OUTCOMES
WITH
NUTRITION SUPPORT”
THE RESPIRATORY SYSTEM

EFFECTS OF MALNUTRITION ON
 DEVELOPMENT
 STRUCTURE

 FUNCTION
EFFECTS OF MALNUTRITION
Ad.Development
#Animal models:
-fetal malnutritionpulmonary hypoplasia
-lung size disproportionately small for body size
Ad.Structure
#Inadequate protein this phasepathologic changes
similar in emphysema
Ad.Function
#Direct correlation (human):
low birth weight and subsequent decreases in pulmonary
function
RESPIRATORY MUSCLE

-Diaphragma weight ~ Body Weight

- ↓Maximal resp.muscle strenght

(MIP&MEP)
loss of muscle mass & myopathy of the
remain-
ing muscle
MALNUTRITION
 ↓peak pressure
generation
limited impact on
endurance
VENTILATORY DRIVE
 Calory& nutrient restrictions ↓ hypoxic
respiratory drive (normal subjects)
 Severe anorexia nervosa (46% IBW)↓VE&
mouth occlusion pressure (=output of
resp. center) due to hypercapnia (reversed
on refeeding) (Ryan etal 1992)
 Malnutrition affects central resp.control
and
muscle strenght
HOST DEFENSES

Malnutrition:
-alters pulmonary defense mechanisms
-animal models (severe malnourishment)
↓alveolar
macrophage/phagocytosis/microbial killing
-inadequate clearance of resp.secretion
(ineffective cough from muscle weakness &
alveolar collapse /atelectase)predisposed
to pulmonary infection
TUBERCULOSIS
Spectrum:
 Asymptomatic latent to disseminated disease

 Disrupts normal hostpulm.& extrapulm

 Poor nutr. & TBthe Greek term aphthisis

( “to waste away” & “consumption”)

 Network of cytokines TNF-ᾳ as the central

role in pathogenesis of TB
 Multiple micronutrient deficiencies during TB
TUBERCULOSIS

 Serum albumin & arm circumf. subnormal 12

month after therapynot fully recovered of
body protein reserve
 Altered amino acids metabolismwasting
 TB & HIV the body cell mass depleted
 Vit.A improves immune response
(animal studies)
Solotorovsky M,1961; Ferraro,1988
 Protein deficiency:
loss of tuberculin test sensitivity
↓lymphocyte proliferation responses to
mycrobial antigens
 IL-2 production
 CD2+ lymphocytes in thymus &
peripheral
Bartow,1990;Mc Murray,1992
NUTRITIONAL STATUS & PROTOTYPICAL LUNG DISEASES

Nutrition in critical illness:

 hypermetabolism
 protein catabolism
 muscle proteolysis

 insulin resistance (impaired glucose

utiliz.)
 hyperglycemia
NUTRITION SUPPORT
 Appropiate amount & composition of nutrients
 Energy Requirement estimated (REEx1.2-1.5)
 Estimate Calory needs by Fick Equation
Vo2=CO+Cao2-Cvo2  invasive monitoring
(pulmonary artery catheter,relative stable pat.)
 Vo2 (ml/min) converted to kilocalories/day
calorie value O2 (4.69-5.05 kcal/L O2 consumed)
or Weir equation if Vco2 (O2 product.) known
SUBSTRATE SUPPLEMENTATION & VENTILATORY
REQUIREMENT

Acute Resp.Failure
proteolysis (endogen protein)
in fasting, glucose 100 g/d (600g/d in septic)
fat emulsion (+minimum 500 kcal/d for spare)
approp. mix.of Carb.+Proten+Fat (individual):
-CHO oxidized ~ CO2> (6 molecules) RQ=1
-Protein oxidized ~ RQ=0.8
-Fat oxidized ~ RQ = 0.7
RESPIRATIONAL QUOTIENT (RQ)

 Substrate utilization
 Allows nutrient administration to be
tailored
patient’s need
 On a kcal per kcal basis:CH produce
21% more
CO2 vs fat
ASPEN 1993:CH REQ.=25-30 KCAL/BW/DAY
ASPEN 2001:

 Basal req :1 kcal/kg/hour (‡5-10%)

 ~activity/stress
 Gucose infusion; max 5 mg/kg/min

* CH 1gr4 kcal,max 6-7.5 g/kg/day

* Energy req,CH+Lipid (70:30 or 60:40)
LIPID
 1gr  9kcal
 Lipid emulsion:

*Source of energy
*prevent EFA deficiency
*↓osmolarity peripheral TPN
* MONITORING IMMUNOLOGIC FUNCTION
FAT REQUIREMENT
 To provide EFA
 EFA cell
membranes,prostaglandins,immune
mediators
PROTEIN REQ.
 Normal 0.5-1,0g/kg/day (in patient may
increase to 1.0-1,5 g/kg/d (ASPEN 2000)
 Nitrogen consumption:
Urine ureum/24 hrx28x4000 mmol (mg/24
hr)
 Protein reg : N consumption 6.25
 Protein req vs Cal.req:
Metab.stress (-) 1gr prot: 30 Cal/kg/d
Metab.stress (+) 2 gr prot. : 40 Cal/kg/d
ELECTROLYTE REQ.
ElectrolytemEq/kg/d daily dose(mEq/d)
----------------------------------------------------------------
-------------------
Na 1-2 50-100
K 1-2 50-100
Mg 0.2-0.5 10-30
Ca 0.2-0.3 10-15
P 0.5-1.0 20-45
Cl 1.0-2.0 50-100
VIT.REQ.
Vit. Req/d
-----------------------------------------------------------------------------------------------------------
------------------------
Thiamin 3.0
Riboflavin 3.6
Pyridoxin 4.0
Niacin 40 mg
Pantothenic acid 15
Folic acid 400 mcg
Biotin 60 mcg
Cyanocobalamin 5 mcg
Ascorbic acid 100 g
Vit A 3300 U
Cholecalciferol 200
Tocopherol 10 mg
Phytonadione 2mg
TIMING & ROUTE OF NUTR.SUPPORT

 Enteral Feeding & Pulmonary Issues

-potential mechanical risks
(tracheobronchial
tree/pleural space
-nasoduodenal route↓ risk of
aspiration
-semirecumbent position
 PEN & pulmonary issues
(peripheral/central)

-central veinconcentrated solution

-ARDS  improve outcome with limited
fluid
-Heparin 6000 U/d ~ ↓ risk of
thrombosis
ARDS/ACUTE LUNG INJURY

ARDS:
-↓ Antioxydant (vit-E,C,retinol,β carotene)↑ lipoperoxides
- Supplementation(-) change in pulm.MR, lower incidence
of MOF/LOS of intensive care/fewer days of mechanical
ventilation
- Dietary lipids ~ eicosanoids profile produced inflammatory
cells
a.linoleic acid (n-6 FA)arachidonic (precussor of many
proinflam. PG & leukotrines )
b.linolenic (n-3FA) eicosapentanoic (~eicosanoids
less inflammatory potential
MALNUTRITION & COPD
 60 % of patients with COPD
 Improvement in nutr.statussurvival >
 Malnutr.& ↓ BW (advanced lung disease)=
Pulmonary cachexia syndrome
(inadequate
 intake from hyperinflation
 hypermetabolic in COPD
 ↑Work of breathing & EE)
 Generally >  ↑REE
COPD
 Inflammatory state (malnutrition)from:
-chronic airway inflammation
-circulating inflammatory mediators
loss of skeletal muscles/weight/fat-
free mass
 ↑ TNFᾳ (induce cachexia) in weight
loss
(absence of an acute infection)
OBJECTIVE OF MNT IN COPD

1.To decrease anorexia

2.To prevented deterioration of

nutritional status in patients with
reduction of respiratory muscle mass,
muscle weakness and problem with
weaning from ventilating support.
(patients with respiratory deficiency
retain CO2)
MNT FOR COPD
1.Growth hormone/anabolic steroid
 adjuvant therapy

 improvements N-balance,BW,LBM,MIP

 protein synthesis

 minimizing thermogenic effect nutritional

replacement by reducing calories needed for

anabolism
2.High fat,low CHO diet(CH: 35-50%,Pr.15-
25%,FAT:20-25%)
3.Att. for ↓K/Ca/PO4resp..muscle function?
4.Specific nutrient: Omega 3,Vit.C
5.Non nutrien : Licophen
6.Texture: PEoralenteral
Oral: soft diet
7.Evaluation:Physical,Intake,SGA,Blood
gas
Analysis,Blood Glucose
ASTHMA
 Dietary fat,rich in fish oil  alter
prostanoid released (from inflam.sel)
 Vit.C,E (antioxidants),Mgmodulate
effects
of airway injury
PULMONARY CANCER
 Disease specific formulas
(enteral/parent.)
-chronic pulmonary disease
-cancer induce weight loss
LEARNING OBJECTIVE OF MNT IN LUNG CA.
1.To list the possible mechanisms of cancer
cachexia
2.To list possible cause of iatrogenic malnutrition
3.To list commonly accepted indications for
nutritional support in surgical and non- surgical
oncologic patients
4.To explain what is safe nutritional regimen in
terms of water, energy and nitrogen
CACHEXIA

A clinical/metabolic syndrome
characterized by:
-weight loss
-weakness
-anorexia
-depletion and derangement of body
compartments, disturbances in water
and electrolyte metabolism,progressive
impairment
of vital function
CLINICAL PRESENTATION OF CACHEXIA

1.Patients appears pale, emaciated face

2.Athropic skin
3.Several skeletal muscle wasting
4.Loss of subcutaneous fat, sometimes
hidden by the presence of oedema
METABOLIC ABNORMALITIES IN CA.
CARBOHYDRATE
 ↑gluconeogenesis from amino acid,lactate,glycerol
 ↑glucose disapperance and recycling
 Insulin resistance

PROTEIN
 ↑muscle protein catabolism
 ↑whole body protein turnover
 ↑liver protein synthesis
 ↓muscle protein synthesis

LIPID
↑lipolyisis/glycerol/fatty acid turnover, ↓lipogenesis & LPL activity
 ↑NEFA (nonconstant) and plasma lipid (nonconstant)
MEDITORS OF MANY METAB.ALTERATIONS
PROTEIN CARBOHYDRATE LIPID
 TNFα proteolysis glycogenesis ↓lipogenis
hepatic pr.synt. gluconeogenesis ↓LPL in fat tissue
↑lactate production
--------------------------------------------------------------------------------------------------------------------------
 IL-1 ↑ hepatic pr.synt. ↑gluconeogenesis ↑lipolysis
↓ LPL synthesis
↑FA synthesis
-------------------------------------------------------------------------------------------------------------------------
 IL-6 ↑ hepatic pr.synt. ↑ lipolysis
↑FA synthesis
--------------------------------------------------------------------------------------------------------------------------
 IFNɤ ↓lipogenesis
↑lipolysis

↓LPL activity
DISEASE-SPECIFIC FORMULAS (LUNG CANCER)

 CHO content <<

 Fat content >>
 High calory density
 Intact protein
 Fiber supplementt
 Anti oxidant (vit.A,C,E,Se,Taurine)
 Ad.Critical care (mechanical ventilation)
*EPA (eicopantopentanoic acid)
*GLA (gammalinoleic acid)
*Antioxidant
*High calory density
*Lung injury,SIRS,ARDS
*No arginine/glutamin/APA/GL/Nucleotide
in severe sepsis (grade B)
 Methode for Enteral
 Feeding pumps
-adults : 10- 15 ml/hr (feeding drips)
-good tolerance + 10-20 ml/4-8 jam
~
calory need (day -3)
ENTERAL NUTR.ROUTE
1.Continued (intragastric/duodenal/jejunal)/24
hr:
1000 ml (day-1)-2000 ml(day 20-more
 25ml/hr (1st 12 hr)- 50 ml (2nd 12
hr),max.100-150m/hrflush 30 ml warm water
2.Intermitten
Bolus (vol>30 ml>250-500ml in 30-60 mt
(to prevent ↑ gastric pH)
Drips (with pause)
ADVANTAGE & EVALUATION
 Critically ill NE post pyloric ↓gastric
residu
 Nitrogen balance, serum protein,energy balance
 Quality of life,morbidity,mortality,LOD (II)
 Tube dislocation (25% patien with NE (IV)
 Head of bed elevation
 Residual stomach?
PARENTERAL NUTRITION
 Inability to consume and absorb adequate
nutrients orally or by EN
 Hemodynamic stability

 Central PEN:

-Amino acids > 5 %

-Dextrose > 20 %
-Lipids
-vit,minerals and trace elemen
-Omolarity >700 mOsm/kg H2O
SELESAI