COPD, Respiratory and Nutrition Disorders Flashcards
How may malnutrition lead to respiratory system problems
malnutrition-> muscle wasting-> trouble breathing
Other functions of the Respiratory System – Lungs
Lungs protect against infection and toxins
• Trapped by sticky mucus substance which keeps airway moist
• Cilia propel mucus and unwanted cells upward to be coughed up or swallowed
• Alveoli cells engulf and destroy bacteria
What is COPD characterized by
- Difficulty breathing
- inflammation and severe limitation of air flow in and out of the lungs
- IN COPD airways become thick and inflamed, more mucus gets produced. This mucus can clog the airways and makes it hard to breathe
In COPD, walls of air sacs get damaged and loose their elastic quality and can get broken
Air spaces get larger and the air gets trapped; it is difficult for the lungs with COPD to delfate
COPD is an umbrella term for group of chronic condition, most commonly __and __
COPD is an umbrella term for group of chronic condition, most commonly chronic bronchitis and emphysema
a few people have both __ and COPD
a few people have both asthma and COPD
What is the leading cause of COPD?
What are the other factors that can lead to COPD
- smoking
Long-term exposure to second-hand smoke, air pollution, dust or workplace fumes and biomass exposure can contribute to COPD
Uncommon genetic disorder- alpha1-antitrypsin disorder is sometimes associated with COPD
DO respiratory infections cause COPD?
Respiratory infections do not cause COPD, but can make people with COPD very sick
Vaccinations are thus important
How does COPD and symptoms progress?
At first COPD may cause no symptoms or only mild symptoms
As disease progresses, common symptoms include shortness of breath, wheezing and chest-tightness, difficulty to exercise and ongoing cough, often with mucus
breathing requires much more energy - can lead to fatigue, weight loss and muscle loss
What is the demographic, most commonly affected by COPD?
COPD is most commonly diagnosed in middle aged individuals. older than 40 years; present in both women and men
COPD is more prevalent in men, but more women die from this disease
Are COPD rates increasing or decreasing? Why?
Rate of COPD is increasing worldwide, due to smoking and increasing air pollution
How can COPD be cured?
There’s no cure for COPD, but progression can be slowed down via lifestyle changes
Define dyspnea
• Dyspnea is labored breathing or Shortness of Breath (SOB)
Define DOE
• DOE Dyspnea on Exertion, or SOBOE
Define exacerbation
• Exacerbation a worsening of symptoms
Define Hypercapnia
• Hypercapnia is the excessive accumulation of CO2 in blood
What are the conditions associated with mild form of COPD? Severe?
Mild: asthma
Severe: emphysema and bronchitis
What are the similarities between all the conditions associated with COPD?
• Dyspnea • Hypercapnia • Increased risk of infections - increased CO2 levels in blood - All these conditions are inflammatory
What are specifics of chronic bronchitis?
- Cough with mucous
* Blue bloater
What are specifics of cemphysema?
- Rapid breathing, Pink Puffer
- Enlarged airspaces in alveoli
- Cough may or may not have mucous
Cachexia definition
Loss of skeletal muscle and fat related to underlying disease condition. Increased risk of osteoporosis.
Obesity and associated risks
Increased CVD and diabetes risk (co-morbidities). Sleep apnea.
Sarcopenia obesity and associated risks
Loss of muscle mass.Loss of muscle mass.
More abdominal or visceral adipose tissue.
Increased CVD risk
What are the conditions associated with blue bloater
Blue bloater (chronic bronchitis type): Fluid retention, risk of heart failure looks like heart failure patient
Physical changes associated with mild to moderate COPD
May not see any physical signs
Common Comorbidities of COPD
- diabetes mellitus/metabolic syndrome
- cancer (lung and other)
- cardiovascular disease
- osteoporosis/osteopenia (lower bone mineral density than normal; precursor to osteoporosis)
- depression, anxiety
WHat are the lifestyle factors associated with COPD?
Smoking, Lifestyle factors,
Lack of exercise Alcohol Obesity
Characteristics of pink puffer
• Pink tone from breathing hard/frequently
• thin, muscle wasting
• sometimes a slightly barrel shape- rounded chest from breathing hard
chest
• little or no cough or expectoration
What is FEV1
Forced Expiry Volume (FEV): FEV1 is the volume of air that can forcibly be blown out in one second, after full inspiration.
Spirometry: Lung function test
Who carries out the Spirometry test
Respiratory technician
How do we measure oxygen saturation?
pulse oximeter
FEV1 cut-offs?
Mild: FEV1 ≥80% predicted
Moderate: 50% ≤ FEV1 <80% predicted
Severe: 30% ≤ FEV1 <50% predicted
Very severe: FEV1 <30% predicted
Classifications of COPD by Severity
COPD is classified by the severity of the patient’s airflow limitation based on post-bronchodilator FEV1. These classifications apply to patients with FEV1/FVC ,0.70.
Gases dissolved in liquids have __
Gases dissolved in liquids have partial pressures, i.e. they exert pressure against membranes, cells
What is diffusion determined by?
Diffusion, across epithelial cells, determined in part by pressures on each side, dissolves into solution and released as a gas
What is hypercapnia? What are the symptoms associated with it ?
condition of abnormally elevated carbon dioxide (CO2) levels in the blood
Morning confussion
Why is hypercapnia typically experienced in the morning?
happens in the morning due to decreased respiration and pulse rates during the night
Why is increased CO2 associated with lower blood pH?
More reactants in the equation gives more products
• CO2+H20↔H2CO3↔(H+ + HCO3 ̄) Bicarbonate
• More H+ = lower blood pH
How kidneys normally compensate for increased H+?
the kidney increases net excretion of H+, and retains the HCO3 with either Na+ or K+
How can respiratory acidosis occur?
If sudden worsening of symptoms (exacerbation) , body may not compensate and respiratory acidosis occurs
Is cachexia improved with optimal nutrient intake? What is the consequent goal?
No or limited improvement with optimal nutrient intake
thus our goal is not gain, but maintenance in such patients
How is GI affected by COPD
Gastrointestinal symptoms may occur due to impaired peristalsis due to lack of oxygenation of gastrointestinal tract
Which form can be used to assess whether the patient is sarcopenic or cachexic? What are the factors assessed?
Subjective Global Assessment Form
- Weight
- Nutrient intake
- Symptoms
- Functional capacity
- Metabolic requirement
How to assess whether the illness is acute or chronic?
Assess energy intake, weight loss, body fat loss, muscle mass wasting, fluid (edema), handgrip strength
Estimated Energy needs to maintain or gain weight:
• (30 to 35) kcal/day x __kg actual body weight
but we still have to monitor is this is sufficient such that there’s no additional weight gain
Protein reqts for COPD
- Typically 1.0 to 1.5 g/kg
* During episodes of stress, infection or exacerbation, on the higher side of the range (1.2 to 1.7 g/kg).
Nutrition Therapy when there is (or risk of) malnutrition:
Which would also be recommended to pink puffer as they have high energy requirements and are often malnourished
- Small, frequent, nutrient dense, high kcal meals and snacks due to shortness of breath and increased speed of satiety
- 6 meals per day
- Soft foods with sauces may be easier to chew and swallow
- Nutrient dense beverages
- Add kcalories with cream, margarine, etc
- Limit low kcalorie or less nutrient dense foods/fluids
- Use convenient or easy-to-prepare meals
- Encourage healthy choices
- May need to limit salt and fluid if fluid retention is a problem, but try not to restrict too much if malnutrition is a major concern (use clinical judgement)
__ are associated with increased energy intake
Oral Nutritional Supplements are associated with increased energy intake
Oral Nutritional Supplements programs that help to increase caloric intake
MedPass or Sip Supp programs: pass with medications
Oral nutritional supplements should be administered in __more __
Oral nutritional supplements should be administered in Small amounts more frequently
How to estimate recommended CHO and fat intake for COPD
Patient preference more important than the percentage of fat or carbohydrate
• A higher calorie (denser, 2.0 kcals/ml) supplement may be beneficial when fluid intake is restricted
What diet is recommended when fluid intake is restricted
A higher calorie (denser, 2.0 kcals/ml) supplement may be beneficial when fluid intake is restricted
Examples of nutrient dense foods
- Enriched oatmeal
- Enriched mashed potatoes
- Enriched puddings and yogurt • Enriched cream soups
- Sauces and gravies
Types of Medications Used in Diseases of the Respiratory System
- Bronchodilators
- Steroids (corticosteroids)
Action of Bronchodilators
Used to open or relax the bronchial tubes and relieve shortness of breath. May be taken as an inhaler or pill.
Side effects of Bronchodilators
Fast heartbeat, shakiness, and cramping of hands, legs, and feet; dry mouth, particularly with the anticholinergics
Severe nausea and vomiting with theophyllines
Action of Steroids (corticosteroids)
Used to reduce
inflammation in the bronchial tubes. May be used as an inhaler or taken orally.
Side effecst of Steroids (corticosteroids)
Side effects depend on the dose, length of use, and whether taken orally or inhaled.
For inhaled steroids, most common side effects include sore mouth, hoarse voice, infections in throat, and cough.
Orally in high doses or low doses for a long period of time, side effects include altered fluid/electrolyte balance, hypertension, mood swings, increased appetite, weight gain, hyperglycemia, osteoporosis, hyperlipidemia, poor wound healing, growth retardation in children.
Prednisone
type of med
Side effects
Corticosteroids
Short-term, high dose nutrition related possible side effects:
- hypertension
- hyperglycemia, steroid induced diabetes
- weight gain, increased appetite
- puffiness, swelling, edema, water retention
- hyperlipidemia
long-term ( 1 g or more, for 6 months or more) use associated with:
- muscle wasting, protein catabolism
- decreased bone mineral density and fractures, calcium wasting
Nutritional implications of corticosteroids (ex. Prednisone)
Diet:
• Low salt/sodium
• Long term use: High calcium/vit D (consider supplements)
• High protein
• May need diabetic diet (monitor glucose, TG)
• May need heart healthy diet (monitor chol, TG)
What is sliding scale insulin? When might it be prescribed?
The term “sliding scale” refers to the progressive increase in the pre-meal or nighttime insulin dose, based on pre-defined blood glucose ranges.
When taking prednisone
Blue bloater symptoms are similar to __ patients
Blue bloater symptoms are similar to heart failure patients
Blue bloater symptoms
- Chronic, productive cough
- Hemoptysis- coughing up of blood or blood-stained mucus from the bronch
- Cyanosis due to hypoxemia (lack of oxygen)
- Peripheral edema
- Prolonged expiration
- Obese
Similar symptoms to HF (bloating, fluid accumulation)
How is blue bloater similar to what we saw with Heart Failure
- Lack of oxygen in circulation
- Heart and lungs are working harder
- Edema makes patient appear bloated
- Cyanosis is a blue tint to the skin/lips (lack of oxygen) • Neck veins distended (right heart failure)
What is digital clubbing, what type of COPD is it typical for ?
Blue bloater
• thickening of flesh under nails
• likely caused by vasodilation in distal circulation, hypertrophy of nail bed tissue
Blue bloater and cardiac/respiratory failure
progressive cardiac/respiratory failure over time
What are the diet recommendations for blue bloater
same recommendations as in heart failure
2000mg of sodium (due to edema)
limit to 1-2 litres; if person has a lot of fluid accumulation-> limit it even more
energy dense diet
Downside of mechanical ventilation
patient will become dependent on it if he stays on it for too long due to muscle atrophy
Intubation via oral route- implications
• Can not eat orally (airway open, and epiglottis can’t close).
• May also be unconscious or heavily sedated
• Usually on a tube-feeding (enteral nutrition) assuming the GI system is working
tube feeding is used - can be used via nose and down to oesophagus
if longer feeding-> directly into the stomach
Tracheostomy- implications
- involves creating an opening in the neck in order to place a tube into a person’s windpipe
Frequently patients with a tracheostomy require a tube- feeding. (either via nose or directly into stomach)
Sometimes swallowing certain textures of foods may be allowed if swallowing has been assessed.
small amount of food might be eaten eventually - Cuff can be inflated. to block the trachea
the person can also still swallow as the tube is lower than trachea-> epiglottis can still cover the wind-pipe- doesn’tt happen early on, but with time they might be able to eat
Is there the best nutrient that has the highest RG, thus the least strain on lungs?
• In theory, fat has a better ratio. Less CO2 produced, but there’s no actual proof
What are the possible implications of having high fat diets by people with COPD?
Higher fat meals may increase satiety and GI disturbances. Also may increase CVD risk.
people with COPD already have slow digestion - > early satiety is not good
What is the worst scenario in terms of RQ
Overfeeding has the highest RQ-> less strain on lungs
Nutrients and their RQs
carbohydrate- 1.0
mixed fuel - 0.85
protein- 0.8
fat- 0.7
Why should overfeeding be avoided?
Overfeeding (providing more 40 kcal/kg unless confirmed/indicated by indirect calorimetry) should be avoided or approached cautiously because
• Excess kcalories and storage of fat contributes to the production of CO2
• increases work of breathing
• increases risk of morbidity/mortality
What is the recommended kcal/kg
35kcal/kg
Intensive Care:
Benefits and risks of Planned underfeeding
- Benefit: less work for the lungs in a critical care situation
- Risk: that patients tend to be underfed anyways in critical care (having tests or procedures).
BMI and COPD prognosis relation
- in mild to moderate COPD, the best prognosis has been found in normal weight or overweight subjects
- in severe COPD, overweight or obese patients are associated with a better survival.-> higher BMI is better
Diet focus: puffer vs bloater
bloater: fluid and sodium limitations
puffer: increasing caloric intake
COPD cycle of malnourishment
Decreased lung function-> increased symptoms-> lower food intake-> malnourishment-> decreased lung funciton
Weight loss and malnutrition prevalence
- ~ 1/3 of people with severe COPD experience severe weight loss
- Up to 60% at risk of malnutrition
Factors related to Inadequate Intake:
- impairments in activities of daily living: (ability to shop for food, ability to prepare meals
- lack of financial resources, lack of support
- decreased appetite
- sense of abdominal fullness and early satiety: (hyperinflation pressure on diaphragm, limited oxygen supply to GI tract
- chewing/swallowing difficulties
- depression
- anxiety
- dry mouth
- fatigue
- chronic sputum production
what is the effect of milk on mucous production? How may problems be resolved?
no proven effect, but patients may still complain about perceived increased mucus production after milk consumption
A hot beverage consumed after milk may help reduce the sensation and clear mucous
Why is milk consumption important in COPD?
Bone mineral density is lower in patients with COPD, and therefore reduced calcium/vitamin D intake could be of concern
When Does COPD Become Palliative Care/Comfort care (DNR)?
- Palliative care: Provide what they would like.
- Severe frequent admissions with limited improvement
- On Maximum therapy
- Dependant on Oxygen
- Severe SOB
- Other co-morbidities (ex. Heart failure)
