Pulmonary Flashcards
what is the primary function of the respiratory system?
gas exchange
what to the lungs enable the body to do?
obtain adequate oxygen to meet cellular metabolic demands
and
remove carbon dioxide produced
healthy _ _ & _ are necessary to supply oxygen and nutrients to all tissues
nerves, blood and lymph
what do the lungs do to already inspired air?
warm, filter and humidify
what is the respiratory centre?
what it involves, where its located & what it does
involves: structures that generate rhythmic respiratory movements and reflexes
Located: medulla and pons
Does: electrical impulses are generated here and are carried by phrenic nerves to the diaphragm and other respiratory muscles
airways have 12 types of _
epithelial cells
most epithelial cells that line the trachea, bronchi and bronchioles have _
cilia
the epithelial surface of alveoli contain _
macrophages
what do macrophages do?
through phagocytosis, the macrophages engluf inert materials and microorganisms and digest them
what is surfactant?
- secreted from alveolar cells
it maintains the stability of pulmonary tissue by decreasing surface tension of fluids that coat the lung
what are the metabolic functions of the lungs?
1. help regulate acid base balance
- body pH is partially maintained by proper balance of CO2 and O2
2. synthesize arachidonic acid (AA)
- that may be converted to prostaglandins or leukotrienes
- these play a role in bronchoconstriction seen in asthma
3. converts angtiotensin 1 to angiotensin 2
- done by angiotensin-converting enzyme (ACE), found mainly in the capillary beds of the lungs
4. can function as a chemical filter
5. protect systemic circulation
- from exposure to high levels of circulating vasoactive substances
malnutrition and the pulmonary system
malnutrition adversely affects
- lung structure, elasticity and function
- respiratory muscle mass, strength and endurance
- the lungs immune defense mechanisms
- control of breathing
what is the effects of a pulmonary diagnosis on nutrition status?
- substantially increase energy requirements
- malnutrition-related impaired immunity increases risk for developing respiratory infections
- hospitalized pts
- lengthy stays
- susceptible to increased morbidity and mortality
Complications of pulmonary dx and their tx can negatively impact:
_
_
- Food intake
- digestion
Absorption & metabolism of most nutrients are affected
what symptoms are often present in pts with pulmonary diagnosis?
- Abnormal production of mucus
- Vomiting
- Tachypnea (rapid and shallow breathing)
- Hemoptysis (spitting up blood)
- Thoracic pain
- Nasal polyps
- Anemia
- Depression
- Altered taste (medication-related)
pulmonary diagnosis often persists in increased energy expenditure related to:
- increased work of breating
- chronic infection
- medical treatments
pulmonary diagnosis often causes reduced intake related to:
- fluid restriction
- shortness of breath
- decreased oxygen saturation while eatings
- anorexia of chronic disease
- GI distress and vomiting
in regard to pulmonary diagnosis there can also be additional limitations related to:
- fatigue-related difficulty with meal prep
- lack of financial resources
- impaired feeding skills (for infants and kids)
- altered metabolism
- food drug interaction
Primary vs secondary pulmonary disorders
primary:
- TB, asthma, lung cancer
Secondary
- associated with CVD, obesity, HIV, sickle cell or scoliosis
acute vs chronic pulmonary disorder
acute:
- airway obstruction, anaphylactic allergy, aspiration pneumonia
chronic:
- CF, COPD
describe how you would assess a pt for pulmonary dx
- obtain history with a focus on:
- smoking, inhalation of toxins, and any other relevant exposure - percussion and auscultation
- imaging procedures, arterial blood gases, sputum cultures and biopsies
- signs and symptoms to look for:
- cough
- dyspnea
- fatigue
- early satiety
- sputum production
- chest discomfort
- weight loss
what are pulmonary function tests and what different types are there?
PFTs are used to diagnose or monitor the status of lung dx
- Designed to measure the respiratory system’s ability to exchange O2 and CO2
Pulse oximetry
- uses light waves to measure O2 saturation of arterial blood
Spirometry
- breathing into a spirometer that gives information on:
- - Lung volume & rate at which air can be inhaled & exhaled
what is CF?
Life-threatening autosomal recessive inherited disorder
what is CF caused by?
mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) protein
CFTR PROTEIN MUTATIONS
the CFRT defect causes impaired transport of _, _, and _.
this results in the production of thick, viscous secretions in:
this leads to increased salt content in _
Cl, Na, and HCO3
- lungs
- pancreas
- liver
- intestines
- reproductive tract
sweat
what are the 2 predominant burdens of CF?
lung disease and malnutrition
“classical” presentation of the CF diagnosis is when an individual has an elevated _ _
sweat chloride (greater than 60 mmol/L)
CF pts present with persistent _, _ and _
chronic cough, dyspnea ( SOB) and wheezing
as CF diagnosis progresses, pts develop _
bronchiectasis
what might you see on physical exam during the diagnosis of CF?
clubbing
in a pt with CF what does lung auscultation reveal?
crackles in lungs and decreased breath sounds
what does the pulmonary function test show in CF pts?
airway obstruction
the spirogram shows decreased expiratory volume and decreased ratio
what is pancreatic insufficiency?
- pancreas fails to make adequate enzymes to digest food in the small intestine
- most common GI complication of CF
- 90% or less pts have fat malabsorption by 1 yeat of age
- steatorrhea: failure to thrive, poor weight gain
- some present with deficiency in fat soluble vitamins
— frequentyl present with suboptimal vit D status
— also suffer from vit K deficiencies
what is pancreatitis?
Abnormal pancreatic secretions cause progressive damage to the pancreas, resulting in acute or recurrent pancreatitis
what is CF-related diabetes (CFRD)?
what is it associated with and when should screening begin?
Associated with poor growth, clinical & nutritional deterioration & early death
Annual CFRD screenings are recommended beginning at age 10 yrs
Bone disease in CF
what is it characterized by and what are the risk factors?
Characterized by ↑ fracture rates, low bone density & kyphosis (increased curvature of the upper back)
Risk factors include:
1. Chronic corticosteroid use
2. Multiple courses of antibiotics
3. Failure to thrive
4. Malabsorption of calcium, Vit. D, Vit. K, Mg
5. Inadequate overall intake
6. Reduced weight-bearing activities
what drug is used to treat CF?
ivacaftor
restores functioning of a mutant CF protein
medical management of Cf consists of:
- chest PT
- Nebulizer therapy
- anti-inflammatory agents
- pulmonary hygiene
- pneumococcal and influenze vaccines
- chronic prophylactic antibiotic use
pancreatic enzyme replacement therapy (PERT) helps…..
helps inhance CHO, protein and fat absorption among CF patients
- it is the first step taken to correct maldigestion and malabsorption
why would we prescribe PPI’s to CF patients?
to ensure duodenal pH is high enough for the PERT capsule to degrade
the amount of PERT a CF patient recieves depends on….
- the degree of pancreatic insufficiency
- quantity of food eaten (&portion of macronutrients)
- type of enzyme used
The dosage of PERT per meal or snack is adjusted based on…
the pts GI symptoms and growth (in kids)
- if GI symptoms cannot be controlled, enzyme dose, pt adherence and enzyme type should be reevaluated
why is growth failure a common problem in CF pts?
Malabsorption
↑ energy needs
↓ appetite
women with a BMI less than _ and men with a BMI less than _ should be referred for a full nutrition assessment for CF
women: less than 22
men: less than 23
in children with CF what should you monitor yearly for?
PTH levels
25 hydroxy-vitamin D levels
Serum calcium
Serum phosphate
Bone Density (DXA) (for older children)
What are the 4 goals of MNT for CF pts?
Increasing muscle strength
Promoting optimal growth
Weight maintenance
Enhancing quality of life
what are the energy recommendations in newborns-2 , ages 2-20 and adult male/female
percentiles and BMI
Newborn-24 months: weight/length greater than or equal to 50th percentile (CDC charts)
Maintaining BMI 50th– 85th percentile for age between 2-20 years
Maintain BMI of 22-27 for adult females and BMI 23-27 for adult males
all CF pts should take 1500 - 2000 IU _ per day and up to 10000 IU/day for CF pts 18 or older
Vitamin D
how much vitamin K should be taken?
1000 mcg or more/day
what is asthma and what are the symptoms?
Chronic disorder that affects airways
- Characterized by bronchial hyper-reactivity, reversible airflow obstruction, airway remodling
Symptoms include:
- Periodic episodes of chest tightness
- Breathlessness
- Wheezing
* symptoms usually worsen at night
what is Extrinsic asthma?
chronic allergic inflammation of airways
what is intrinsic asthma?
triggered by nonallergic factors such as exercise, certain chemicals and extreme emotions
why might we not provide pts with chronic corticosteroid therapy?
can ↑ risk of osteopenia, bone fracture or steroid-induced hyperglycemia
what are the essential compoents of medical management for asthma?
- routine monitoring of symptoms and lung function
- Patient education
- Control of environmental triggers
- Pharmacotherapy
- —Tailored to the individual
- —Step-wise – dependent on attack classification
what is the RD’s purpose in treating asthma?
Addresses dietary triggers
Corrects energy & nutrient deficiencies/excess in the diet
Educates the pt on personalized diet
Monitors growth (in children)
Watches for food-drug interactions
_ and food allergies are 2 common dietary triggers of asthma
GERD
What should you be aware of if the pt is on maintenance oral steroids?
potential drug-nutrient interactions
what are the risk factors for COPD?
Smoking
Biomass fuel used for cooking and heating
occupational smoke or dust
Air pollution
Genetic factors
a decrease in food intake and malnutrition are associated with COPD, Why?
Respiratory muscle weakness
↑ disability
↑ susceptibility to infection
Hormonal alterations
what is chronic bronchitis & what is emphysema
Chronic bronchitis – if primary, more likely to see hypoxia, hypercapnia, pulmonary HTN, & right heart failure
emphysema – if primary, suffer from greater dyspnea & cachexia (lungs less flexible and less able to act as filters)
The two may co-exist in varying degrees
what are some of the causes of COPD exacerbations?
Allergies
smoking
Congestive heart failure (CHF)
Pulmonary embolism 9blood clot caught in artery in lungs)
pnemonia
Systemic infections (bacterial or viral)
Osteoporosis in COPD pts predisposes them to:
Vertebral fractures
& alters the configuration of the chest wall
Frequent COPD exacerbations ↑ the severity of …
& leads to…
chronic system inflammation
Leads to bone loss by inhibiting bone metabolism
what does the prognosis of COPD depend on?
severity of disease,
genetic predisposition,
nutritional status,
environmental exposures,
acute exacerbations
what is the main treatment for COPD?
inhaled bronchodilators
- usually given by metered dose inhalers
- in cases of devere dyspnea, may be administered in nebulized form
what do hypoxemic pts require?
supplemental oxygen
pts who progress to respiratory failure may require …
mechanical ventilation
what are some of the common reasons for early readmission to hospital after acute exacerbation of COPD?
Depression
Smoking
Anxiety
GERD
Reduced functional status
Unwillingness to use oxygen
malnutrition
because malnutrition risk is increased in COPD pts what is required?
Extra energy required for the work of breathing & to combat frequent/recurrent respiratory infections
what is an independent predictor of mortality in COPD pts?
low body weight
what are the PRIMARY targets for intervention of COPD
inadequate food intake and poor appetite
what nutrients are commonly depleted in COPD pts?
- Protein
- Calcium
- Magnesium
- Potassium
- Phosphorous
- Contribute to respiratory muscle function impairment
what are the 2 main goals in managing COPD related hypermetabolism and how are these accomplished?
- Prevention of weight loss
- Prevention of loss of lean body mass
Accomplished via:
1. Nutritionally dense small, frequent meals
2. Encouraging the pt to eat the main meal when energy levels are highest
3. Providing adequate calories, protein, minerals & vitamins to maintain a BMI of 20-24
4. Enhancing availability of foods requiring less preparation
5. Limitation of alcohol to <2 drinks/day
6. Rest period before meal times
iron deficiency anemia is seen in 10-30% of COPD pts
Correcting the deficiency improves _
dyspnea
what are the primary goals of MNT in COPD pts?
Facilitate nutritional well-being
Maintain appropriate ratio of lean body mass to adipose tissue
Correct fluid imbalance
Manage drug-nutrient interactions
Prevent osteoporosis
in pts with COPD nutritional depletion may be evidenced by:
Low body weight for height
Decreased grip strength
it is crucial to remember that energy balance and _ are intertwined
nitrogen balance
what is the protein recommendation for COPD pts?
1.2-1.5 g/kg of dry body weight per day
those continuing to smoke with COPD will require additional …
vitamin C
those with COPD who are retaining fluid may be required _ and _ restriction
sodium and fluid restriction
how much fluid is recommended for COPD pts?
ages 18-60
& 60+
18-60 yrs = 35 ml/kg body weight daily
60 + yrs = 30 ml/kg body weight daily
what are the possible reasons for reported difficulty eating in COPD pts?
Low appetite
Increased breathlessness when eating
Difficulty shopping & preparing meals
dry mouth
Early satiety & bloating
Anxiety and depression
Fatigue
how is pulmonary cachexia defined and what are the main treatment?
defined as BMI less than 17 in men and less than 14 in women
Pharmacotherapy, respiratory rehab & nutrition counseling are the mainstays of pulmonary cachexia tx
any sudden drop in _ is a mark of developing osteoporosis
height
most pts with active pulmonary TB infections present with:
Chronic cough
Prolonged fever
Night sweats
Anorexia
Weight loss
TB pts are to be contained in respiratory isolation until the _ _ comes back negative
sputum smear
for pts with TB nutritional supplementation is necessary until a BMI of _ is achieved
18.5
what are the nutrition related symptoms of active TB?
- weight loss
- cachexia
- low serum concentration of leptin
what is the recommended energy intake of pts with TB?
35 to 40 kcal/kg of ideal body weight
- if a more serious infection is present suchbas HIV, increase energy by 20-30% to maintain body weight
what is the protein recommendation for pts with TB?
1.2-1.5 g/kg ideal body weight
tumors affecting the lower respiratory tract are _
heterogenous
bronchogenic carcinomas are comprised of:
Squamous cell carcinoma
Adenocarcinoma
Small cell undifferentiated carcinoma
Large cell undifferentiated carcinoma
how is lung cancer typicalled detected in an asymptomatic smoker?
routine chest radiograph
what symptoms might lung cancer present with?
symptoms:
Related to the tumor itself (e.g., obstruction)
Related to local extensions of the tumor or widespread metastases
Experienced systemically, such as anorexia, weight loss, weakness and paraneoplastic syndromes
in pts with lung cancer, pain and fatigue are very common.
Pain may be _, _ or _
in the lungs, musculoskeletal or in the bones
lung cancer management choices depend on:
Tumor cell type
Tumor stage
Resectability of the tumor
Suitability of the pt for surgery
some lung cancer pts will recieve palliative treatment which can include:
Psychologic support,
Control of distressing symptoms
Palliative chemotherapy &/or
Palliative radiotherapy
MNT for lung cancer
National Comprehensive Cancer Network (NCCN) guidelines encourage
- Treatment of reversible causes of anorexia such as early satiety
- Evaluation of the rate & severity of weight loss
- Treatment of symptoms interfering with food intake
- Nausea and vomiting; dyspnea; mucositis, constipation; pain - Assessing use of appetite stimulants
- Provision of nutritional support (EN or PN)
what is cancer cachexia syndrome?
Presence of a metabolic state that leads to energy and muscle store depletion
- Pts lose adipose & skeletal muscle mass
Wt loss is irreversible & worsens regardless of nutritional intake
nutrition repletion is difficult in advanced lung cancer because:
Dyspnea & fatigue interfere with food prep & consumption
Altered sputum changes the taste of food
Early satiety results from flattening of the diaphragm
Nausea and indigestion are side effects of medications
Lack of motivation to eat is common secondary to depression
MNT for lung cancer
what are the accepted components of oral nutrition therapy in lung cancer pts?
Small, frequent meals high in calories and protein dense
Provision of adequate calories > REE
Rest before meals
Meals requiring minimal preparation
Oral nutrition supplements (homemade or prepared)
in pts with lung cancer, prokinetics can be used to treat …
delayed gastric emptying
ghrelin lowers _ use and stimulates _
fat use
stimulates feeding
what is obesity hypoventilation syndrome?
Defined as
- BMI >30
- Arterial CO2 >45 mm Hg when awake
obstructive sleep apnea is a common chronic disorder characterized by:
Loud snoring,
Excessive daytime sleepiness
Witnessed breathing interruptions &/or
Awakenings related to gasping or choking
what is used to classify whether obstructive sleep apnea (OSA) is mild, moderate or severe?
number of episodes per hour or hyponea per hour
what is the treatment for obesity hypoventilation syndrome?
continuous positive airway pressure (CPAP)
what is pleural effusion and what can it present with?
Accumulation of fluid in the pleural space
- Can be asymptomatic
- Can present with:
— Shortness of breath
— Chest pain
— Symptoms related to the underlying cause (e.g., pneumonia, CHF)
Effusions can be unilateral or bilateral
management of pleural effusion typically involves drainage of fluid either to:
.
.
Make a diagnosis, or
Relieve symptoms
In those with large effusions
MNT for pleural effusion should be directed toward…
the underlying disorder causing the pleural effusion
what is chylothorax and what is it caused by?
Rare cause of pleural effusion
Caused by disruption or obstruction of the thorracic duct, resulting in leakage of chyle into the pleural space
Pleural fluid triglyceride concentration of >_ mmol/L strongly supports chylothorax diagnosis
1.24
chylothorax may result from nontraumatic causes such as:
.
.
or result from surgical trauma
.
.
non traumatic causes:
- Sarcoidosis
- Benign idiopathic chylothorax
surgical trauma:
- Post-op chylothorax
- Postpneumonectomy chylothorax
what are the goals of chylothorax treatment?
medical
Treat the underlying condition
Drain the pleura to relieve dyspnea
chylothorax
If pleural drainage & treatment of underlying condition are not effective, may require …
thoracic duct ligation or pleurodesis
what is the MNT goal for treated chylothorax
reduce the flow of chyle
- Particularly in those with high volume chylous draining (<1L/day)
implement high protein, low fat (less than 10 g/day) diet
decreasing fat intake will result in less fat to be absorbed in the GI, thus reducing chyle production
what are the possible side effects of consumption of MCTs
GI upset
Steatorrhea
Hyperlipidemia
as chylous drainage declines, _ intake can be increased gradually
fat
may take 7-10 days for chylous drainage to clear
acute respiratory distress syndrome (ARDS)
is a clinical state in which pts develop….
Diffuse pulmonary infiltrates
Severe hypoxia
Respiratory failure
In ARDS, alveoli get filled with bloody, proteinaceous fluid that interferes with _ _
gas exchange
in Acute Respiratory Distress Syndrome (ARDS) pts present with:
Acute onset of shortness of breath
Tachypnea
Hypoxemia
what does the medical treatment of ARDS involve?
Treatment of the underlying cause
Mechanical ventilatory support
ICU including sedation with or without paralytic drug
Maintenance of hemodynamic stability
Prevention of complications (e.g., aspiration pneumonia, hyperglycemia)
Nutrition support
Pharmacotherapy (e.g., corticosteroids, exogenous surfactant)
in pts with ARDS, nutrition support is necessary for preventing:
Cumulative caloric deficits
Loss of lean body mass
Malnutrition
Deterioration of respiratory muscle strength
overfeeding in ARDS pts can lead to:
Stress hyperglycemia
Delayed weaning from the ventilator
Delayed wound healing
what is pneumonia?
list the various kinds and those who are more susceptible
An inflammatory condition of the lungs causing chest pain, fever, cough & dyspnea
Various kinds:
- Ventilator associated
- Hospital-acquired
- Aspiration acquired (viral or bacterial)
- Aspiration pneumonia
Individuals who are immune-compromised are more susceptible
what are the 2 pre-conditions of aspiration pnemonia?
- Breach in normal defense mechanism
- Large enough inoculum enters the lungs
what conditions predispose someone to aspiration pnemonia?
Impaired level of consciousness
Dysphagia
Gastric reflux, disorders of or surgery on the upper GI tract
Mechanical disruption of glottis closure (e.g., tracheostomy, placement of NG)
Protracted vomiting, EN feeding at less than 45-degree angle, persistent recumbent position
what is the main treatment of pneumonia?
supporting of pulmonary function
MNT for pneumonia
Direct tube feedings into the small bowel vs. stomach
Continious feeds preferred over bolus feeds
Elevate head of bed to 30-45 degrees
Use prokinetic agents (e.g. Motilium)
Minimize sedative use
Optimize oral hygiene
what is bronchopulmonary dysplasia (BPD)?
Chronic neonatal lung disease seen in premature infants requiring mechanical ventilation and oxygen therapy for acute respiratory distress
BPD occurs in 40% of preterm neonates <28 weeks gestational age
Condition is characterized by impairment of alveolarization
Many require respiratory support
- Periodic attempts are made to wean infants from ventilator support
- Aim to minimize suctioning to limit tracheal and bronchial injury
Medical management is targeted at
- Minimizing further injuries
- Optimizing growth and recovery
Most infants have a modest fluid restriction of - ml/kg/day
140-150
if diuretics are prescribed for BPD, infants may experience….
electrolyte abnormalities
in infants with BPD, energy needs are _ - _% higher than for healthy infants
aim for - kcal/kg/day during active disease
15-20%
140-150
in infants with BPD aim for _ - _ g protein/kg body weight
3.5 - 4.0g
for infants with BPD, amino acids are administered within the first 24 hours of life because they…..
Are well tolerated
Improve glucose tolerance
Create positive nitrogen balance
in infants with BPD, lipids are held or administered in small quantities because they can….
Cause hyperbilirubinemia
Increase risk of kernicterus
for infants with BPD what is the fat recommendation?
4.4-6 g/kg fat/ 100 kcal
use of corticosteroid & diuretics in BPD infants can lead to ….
urinary loss of calcium & decreased bone mineralization
Osteopenia of prematurity is common in infants with BPD resulting from _ & _ deficiencies
Ca & P
infants with BPD Ca & P levels are monitored every _ - _ weeks
1-2 weeks
for infants with BPD, PN is continued along with EN until feeding volume reaches _ ml/kg/day
100
