1. NUTRITION CONSIDERATIONS FOR PULMONARY DISEASES www.reliamed.com

2. What do we mean by Pulmonary Disease For this presentation, Pulmonary Disease includes: 1. Diseases that directly decrease pulmonary function: COPD, asthma, etc… 2. Diseases that indirectly decrease pulmonary function: Neurological diseases, such as ALS, that eventually lead to permanent vent dependence Acute Respiratory Distress Syndrome Developmental diseases, such as Cerebral Palsy

3. OBJECTIVES Understand the relationship between poor nutrition and pulmonary function and vice versa. Know what parameters to monitor a patients nutritional status during pulmonary disease or times of decreased pulmonary function Know how someones energy and macronutrient needs change when pulmonary function decreases Identify the nutritional risks or considerations of aspiration, refeeding syndrome, and weaning from a ventilator Identify common medications used for decreased pulmonary function and their associated nutritional complications

4. How Poor Nutrition Affects Pulmonary Function Malnutrition adversely affects: lung structure elasticity respiratory muscle mass and strength lung immune function control of breathing Examples: Respiratory muscles break down, just as skeletal muscles do, in times of starvation or stress Hypoproteinemia contributes to pulmonary edema by decreasing osmotic pressure Decreasing surfactant contributes to the collapse of alveoli and increases the work of breathing The supporting connective tissue of the lungs is composed of collagen, which requires vitamin C for synthesis Malnutrition, leading to decreased immunity, increases risk of respiratory infections L.K. Mahan, S. E. Escott-Stump. 2008. Krauses Food & Nutrition Therapy, 12 th Edition. Saunders Elsevier. St. Louis, Missouri. pg 901-919.

5. 1. Decreased pulmonary function increases a persons nutritional needs How Pulmonary Status Affects Nutrition Due to: Increased effort required from pulmonary muscles to breathe Increased incidence of chronic infections Being sick increases a persons nutritional requirements

6. 2. Decreased pulmonary function decreases a persons oral intake of food and nutrients Due to: Shortness of breathe and decreased O2 sat while eating decreases appetite Anorexia associated with chronic disease GI distress and vomiting Pulmonary edema necessitates fluid restriction, limiting calories from juices, pop, milk, and other beverages Decreased pulmonary function causes general fatigue, making food preparation difficult How Pulmonary Status Affects Nutrition

7. A Vicious Cycle Malnutrition Poor lung growth Decreasing respiratory muscle tone Chronic infection Chronic inflammation Declining Pulmonary Status Increased effort with breathing Adverse effects of meds Anorexia Fatigue L.K. Mahan, S. E. Escott-Stump. 2008. Krauses Food & Nutrition Therapy, 12 th Edition. Saunders Elsevier. St. Louis, Missouri. pg 901-919.

8. From quality awareness, comes quality of life ~Unknown Goal of Nutrition Therapy during pulmonary disease: To prevent or minimize loss of respiratory muscle mass and maximize pulmonary function, while at the same time providing maintenance or repletion therapy American Society for Parenteral and Enteral Nutrition. 2008. Nutrition Support Core Curriculum: a case-based approach---The Adult Patient. Editor: M.M. Gottschlich. Silver Spring, MD. Pg 489-497. Picture courtesy of : www.careinfusion.com

9. Parameters to assess and monitor nutrition status 1. Weight and Height Are they at a healthy weight for their height, as identified by BMI? <18: underweight 18-25: healthy 25+: overweight 2. Recent history of weight loss or gain Have they lost weight recently? Losing 10% of body weight or more in 6 months is indicative of malnutrition 3. Appetite and/or enteral regimen adherence Has their appetite decreased? Are they able to reach goal rate and duration for their tube feedings (if needed) 4. BMP and electrolyte lab values 5. Respiratory Quotient and PCO2/PO2 A high RQ can be caused by overfeeding and increases pulmonary stress L.K. Mahan, S. E. Escott-Stump. 2008. Krauses Food & Nutrition Therapy, 12 th Edition. Saunders Elsevier. St. Louis, Missouri. pg 901-919.

10. Nutritional Requirements

11. GOAL: Meet caloric needs without overfeeding Pulmonary patients typically have increased caloric needs; HOWEVER, overfeeding increases strain on pulmonary system and can lead to decreased function General Guideline: 25-30 calories per kg body weight Example: Patient X weighs 160 pounds and is 45 yo. Step 1. Divide by 2.2 to find weight in kg (160 / 2.2 = 72.7 kg) Step 2. Multiply by 30 to find daily calorie needs What do I use for body weight? -If patient is experiencing a great deal of edema, use patients usual dry weight -If patient is obese, you must adjust the body weight to avoid overfeeding Caloric Needs American Society for Parenteral and Enteral Nutrition. 2008. Nutrition Support Core Curriculum: a case-based approach---The Adult Patient. Editor: M.M. Gottschlich. Silver Spring, MD. Pg 489-497.

12. Protein needs are slightly increased in patients with pulmonary disease Why are protein needs increased? To maintain or restore lung and muscle strength and promote immune function General Guideline: 1.2-1.5 grams protein per kg body weight (Average healthy individual requires 0.8-1.0 grams/kg) Example: Patient X weighs 160 pounds. Step 1. Divide by 2.2 to find weight in kg (160 / 2.2 = 72.7 kg) Step 2. Multiply by 1.2 and 1.5 to find daily protein needs (1.2 X 72.7 = 87 grams AND 1.5 X 72.7 = 109) Patient X requires between 87-109 grams of protein/day Protein Needs American Society for Parenteral and Enteral Nutrition. 2008. Nutrition Support Core Curriculum: a case-based approach---The Adult Patient. Editor: M.M. Gottschlich. Silver Spring, MD. Pg 489-497.

13. How much food is 87-109 grams of protein? Step 1. To find out, consider the following info: 1 oz of meat = 7 grams 1 cup of milk = 8 grams 1 oz of cheese = 8 grams 1 egg = 7 grams ½ cup of dried beans = 7 grams Step 2. To consume 87-109 grams of protein, this patient would need 12 servings of these foods (divide # of grams needed by 7) Example: 3 eggs at breakfast, 3 oz of meat at both lunch and supper, and a glass of milk at each meal would meet this patients needs 3 X 7 = 21 grams from eggs 6 X 7 = 42 grams from meat at lunch and supper 3 X 8 = 24 grams from dairy Total of 87 grams Protein Needs

14. Recommend high fat, low carb diet when trying to wean or during periods of acute respiratory distress Recommend the following ratios: Protein: 15-20% of total calories Fat: 30-45% of total calories Carbohydrate: 40-55% of total calories Excess carbohydrate increases CO2 production and increases patients reliance on assistance Fat and Carbohydrate Needs American Society for Parenteral and Enteral Nutrition. 2008. Nutrition Support Core Curriculum: a case-based approach---The Adult Patient. Editor: M.M. Gottschlich. Silver Spring, MD. Pg 489-497.

15. Disease-Specific Enteral Formulation Most common formulas include Oxepa and Pulmocare There is limited evidence that pulmonary formulas (high fat, low carb) have clinically significant benefits compared to standard or nutrient-dense formulas that provide adequate energy, regardless of carbohydrate to fat ratio. Overfeeding calories has a greater impact on CO2 production than high carb feedings We stress providing accurate calories rather than low carb formulas. High fat formulas are generally less tolerated than standard formulas (This means patients typically have high residuals and feel uncomfortable because fat decreases motility and sticks around in the gut longer) Standard formulas are much less expensive and often have better coverage by insurance companies. American Society for Parenteral and Enteral Nutrition. 2008. Nutrition Support Core Curriculum: a case-based approach---The Adult Patient. Editor: M.M. Gottschlich. Silver Spring, MD. Pg 489-497.

16. Nutrition-Related Considerations for Pulmonary Disease 1. Aspiration 2. Re-feeding Syndrome 3. Weaning from a ventilator

17. Aspiration Aspiration is the main cause for respiratory infections, particularly pneumonia These increase the risk for aspiration: High residuals Gastroparesis or impaired gastric motility Difficulty swallowing or chewing Strategies to prevent aspiration: Increase the head of bed to at least 30 degrees, preferably 45 Vent stomach before feeding Control secretions

18. Re-Feeding Syndrome Refers to the drastic drop in plasma electrolytes following the reintroduction of adequate nutrition to a severely malnourished patient Most pulmonary patients are malnourished to some degree as their disease progresses Can occur in the first week of feeding adequate nutrition to those who have been significantly malnourished for a long time Characterized by low serum K+, Mg+, P+ Can cause heart failure and/or resp. failure Avoided by gradual reintroduction of nutrition

19. Weaning from a ventilator Primary reason for prolonged vent dependence is pulmonary failure However, dependence has been linked to both overfeeding and underfeeding Nutrition goal: Feeding adequate nutrition without excessive calories Excessive CO2 production increases minute ventilation to reduce PCO2

20. PATIENTS WITH PULMONARY DISEASE ARE AT NUTRITION RISK AND SHOULD UNDERGO NUTRITION SCREENING TO IDENTIFY THOSE WHO REQUIRE FORMAL NUTRITION ASSESSMENT AND A PLAN OF CARE ENERGY INTAKE SHOULD BE KEPT AT OR BELOW ESTIMATED NEEDS ROUTINE USE OF MODIFIED CARBOHYDRATE AND FAT NUTRITION FORMULATION IS NOT WARRANTED SERUM PHOSPHATE LEVELS SHOULD BE MONITORED CLOSELY IN THESE PATIENTS Review: ASPEN Nutrition Guidelines for Pulmonary Diseases American Society for Parenteral and Enteral Nutrition. 2008. Nutrition Support Core Curriculum: a case-based approach---The Adult Patient. Editor: M.M. Gottschlich. Silver Spring, MD. Pg 489-497.

21. Pulmonary Medication Interactions Bronchodilators relax smooth muscles Ex. Albuterol Antibiotics Protect against infections Anticholinergic Anti-histamines Ex. Benedryl Suppress allergic response to stimuli Anti-inflammatory agents Corticosteroids (Prednisone) Suppress airway inflammation Side Effects: dry mouth/throat nausea vomiting diarrhea hand tremors headache dizziness GERD

22. The big one: Corticosteroids Creates increased appetite and insomnia Long term: weight gain Insulin resistance: Long term: hyperglycemia Sodium retention: Long term: fluid retention and edema Creates negative Ca++ balance Long term: risk for osteoporosis

23. CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) A Closer Look: Emphysema Chronic Bronchitis Asthma

24. Nutritional Complications specific to COPD Decreased food intake Due to: Morning headache and confusion from hypercapnia Fatigue Anorexia from lack of oxygen Difficulty chewing and swallowing from dyspnea Increased nutritional needs Due to: Degree of airflow obstruction increasing work of breathing Gas diffusing capacity, CO2 retention, and inflammation induce hormones and cytokines that increase metabolic needs Constipation or Diarrhea Due to: Low fiber intake (constipation) Impaired peristalsis secondary to lack of O2 to GI tract (diarrhea)

25. GOALS of Nutrition Therapy specific to COPD Maintain optimal energy balance to preserve visceral and somatic proteins. COPD patients have been shown to need 94-146% calories as a healthy individual of similar size. Avoid overfeeding, which reduces pulmonary fxn Optimize macro-and micronutrient intakes Adequate fluid, fiber, and exercise can ease constipation Proper balance of protein, fat, and CHO can improve pulmonary fxn Meet the dietary guidelines for Mg+ and P+ to aid in muscle contraction and relaxation Monitor risk for osteoporosis, as DEXA scans have demonstrated that those with COPD to have reduced bone density

26. TIPS and TRICKS for coping with COPD If bloating is a problem, avoid foods associated with gas formation Rest before meals Eat small, frequent meals of energy-dense foods Eat slowly, chew foods well Engage in social interaction during meals Link with community resources Meals on Wheels and congregate meal programs

27. A closer look at: Asthma

28. Nutrition implications specific to Asthma Etiology is yet unclear Nutritional factors, such as maternal diet during pregnancy, diet during infancy and toddlerhood, and obesity have been hypothesized to be implicated with asthma---Vague! Asthmatic symptoms may be aggravated by allergen exposure, including certain foods, such as: shrimp, food additives (such as sulfites), and botanicals (such as citronella in insect repellents, rusty-leafed rhododendron in natural honeys, and strawberry leaf in herbal teas)

29. Foods and/or nutrients currently being studied to aid in asthma treatment Omega 3 and Omega 6 fatty acids (Decrease production of bronchoconstrictive leukotrienes) Antioxidant nutrients (Protect airway tissues from oxidative stress) Magnesium (smooth-muscle relaxant and anti-inflammatory agent) Methylxanthiness, such as caffeine (bronchodilator)

30. GOALS of Nutrition Therapy specific to Asthma Individual evaluation for environmental triggers Diet of wholesome foods to provide optimal energy, nutrients, and phytonutrients Correction of diagnosed energy and nutrient deficiencies or excesses Medication-food-nutrient interactions

31. Thank you for participating! To take the posttest for this course click here. Once you have completed the posttest, you can email it to nutrition@reliamed.com or fax it to 763-255-3956.click here nutrition@reliamed.com