Respiratory Disorders and Nutrition

Question 1

What are the functions of lungs?

Answer 1

– gas exchange
– 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

Question 2

What is COPD?

Answer 2

Chronic Obstructive Pulmonary Disease

Question 3

What are the types of COPD?

Answer 3

1) Chronic bronchitis –> Chronic productive cough

2) Emphysema –> Permanent abnormal enlargement of airspaces

Question 4

Cachexia is linked to

Answer 4

Emphysema type. Loss of skeletalmuscleandfat. Increasedriskof osteoporosis.

Question 5

Obesity is linked to

Answer 5

Chronic Bronchitis type. Increased Fat and CVD risk.

Question 6

Sarcopenic obesity is linked to

Answer 6

Loss of muscle mass. More abdominal or visceral adipose tissue. Increased CVD risk.

Question 7

What is the “Blue Bloater”?

Answer 7

■ Predominant chronic bronchitis type COPD
– Chronic bronchitis patients may start to have signs of right heart failure (sometimes called cor pulmonale)
■ edema makes patient appear bloated
■ cyanosis is a blue tint to the skin/lips due to deoxygenated blood
■ Neck veins distended
– frequent cough and expectoration (sputum) are typical, productive cough
– digital clubbing
■ thickening of flesh under nails
■ likely caused by vasodilation in distal circulation, hypertrophy of nail bed tissue

Question 8

What is the “Pink Puffer”?

Answer 8

– Predominant emphysema type
– Exacerbations and work of breathing result in pink tone to face and constant puffing
– Patients may be very thin with a barrel chest
– They typically have little or no cough or expectoration

Question 9

What are the signs for lean muscle mass loss in COPD?

Answer 9

■ Quite common, and can even occur in those with stable COPD and/or stable weight. Look for visual signs of muscle wasting.
■ Exercise is beneficial to prevent loss of lean body mass.
■ In more severe stages of COPD, exercise may not be feasible due to shortness of breath.

Question 10

What are comorbidities that are related to COPD?

Answer 10

■ diabetes mellitus/metabolic syndrome
■ cancer (lung and other)
■ cardiovascular disease
■ Smoking, 
■ Lifestyle factors,
■ Lack of exercise Alcohol Obesity
■ osteoporosis/osteopenia (lower bone mineral density than normal; precursor to osteoporosis)
■ depression, anxiety

Question 11

How is the BMI affected in COPD?

Answer 11

■ 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.

Question 12

What are the estimated energy requirements in COPD?

Answer 12

■ Physiological stress (severity of inflammation) can increase requirements. Needs can vary between individuals and within the same individual.
■ Estimated energy should range from 25 - 35 kcal/kg, dependent on weight, weight history, appetite, coexisting disease process, and nutritional deficits.
■ Typically use 30 kcal/kg.
■ Adjust as necessary to achieve goals.

Question 13

What are the risks of overfeeding in COPD?

Answer 13

■ Predictive Energy Equation with added Stress factors may over-estimate
■ 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

Question 14

What are the benefits of underfeeding in COPD in ICU?

Answer 14

■ Permissive or planned underfeeding may have some benefits in terms of being less work for the lungs in a critical care situation
■ On the other hand, there is a risk that patients tend to be underfed anyways in critical care (having tests or procedures). Need to monitor actual intake closely.

Question 15

What are the primary goals of nutrition care in COPD?

Answer 15

■ Nutritional well-being, maintain energy balance
■ Maintain lean body mass
■ Correct fluid imbalance
■ Prevent osteoporosis
■ Manage drug-nutrient interactions

Question 16

What are the protein requirements in COPD?

Answer 16

■ Want to ensure that protein needs are met to
prevent lean muscle mass wasting.
■ Commonly 1.0 to 1.5 g/kg would be recommended, which is not difficult to achieve in someone who is eating normally/adequately, but can be difficult to achieve in someone with poor appetite
■ During episodes of stress, infection or exacerbation, protein requirements would be on the higher side of the range ( 1.2 to 1.7 g/kg).

Question 17

Should we increase the %fat in the diet of patients with COPD?

Answer 17

■ Intheory,fathasabetter ratio. Less CO2 produced.
■ Nopractice-basedevidence that increasing fat intake makes an improvement.
■ Higher fat meals may increase satiety and GI disturbances. Also may increase CVD risk.

Question 18

What are the dangers of malnutrition in COPD?

Answer 18

■ Less respiratory muscle mass
■ Less immune defense mechanisms. More likely to get infections
■ Low protein and iron, low Hg = diminished oxygen-carrying capacity.
■ Hypoproteinemia = diminished colloid osmotic pressure = pulmonary edema
■ Less surfactant, collapsed alveoli, increased work of breathing

Question 19

How is the pulmonary function measured?

Answer 19

– Oxygen saturation (pulse oximetry)

– pH (blood test)

Question 20

What is a spirometry?

Answer 20

Lung function test
– Assess severity of disease
– Respiratory technician may perform various lung function tests
– Forced Expiry Volume (FEV)
– FEV1 is the volume of air that can forcibly be blown out
in one second, after full inspiration.

Question 21

How is the amount of CO2 measured in blood?

Answer 21

■ In the blood, most (about 90%) of the CO2 is in the form of bicarbonate ion (HCO3-).
■ Therefore, the CO2 blood test is really a measure of your blood bicarbonate level.
■ CO2 +H20↔H2CO3 ↔(H+ + HCO3 ̄ )

Question 22

What is respiratory acidosis?

Answer 22

■ More CO2 if less ventilation (hypoventilation)
■ More reactants in the equation gives more products
■ CO2+H20↔H2CO3↔(H+ + HCO3 ̄)
■ More H+ = lower blood pH value (acidemia)

Question 23

How does the liver compensate for decreased ph in blood?

Answer 23

the kidney increases net excretion of H+, and retains the HCO3 with either Na+ or K+

Question 24

What is respiratory alkalosis?

Answer 24

■ Opposite of acidosis
■ increased blood pH due to hyperventilation
■ Hyperventilation causing more CO2 to be expired, and less CO2 in blood (less H+)

Question 25

How does the liver compensate for increased ph in blood?

Answer 25

the kidney conserves H+, and instead excretes Na+ or K+

Question 26

What is Metabolic acidosis?

Answer 26

■ Metabolic acidosis is all types of acidosis not caused by
excessive CO2.
– Example: in severe diarrhea there can be a loss of
base.

Question 27

What is metabolic alkalosis?

Answer 27

■ Metabolic alkalosis is all types of alkalosis not related to lower levels of CO2.
– Example in severe vomiting there can be loss of acid.

Question 28

What are the Two key questions in screening for malnutrition

Answer 28

■ Have you been eating poorly due to a decreased appetite?

■ Have you lost weight without trying? (i.e. non-intentional versus intentional weight loss)

Question 29

How is the nutritional assessment done?

Answer 29

■ Patient history. Determine :
– Weight change; % wt loss/time, % UBW
– Is ascites or edema affecting the weight?
– Physical signs of muscle wasting?
– Dietary intake change
– Gastrointestinal symptoms (constipation/GERD/diarrhea/ N&V may occur due to impaired peristalsis due to lack of oxygenation of gastrointestinal tract and other co-morbid conditions)

Question 30

What are the Short-term nutrition related possible side effects of corticosteroids?

Answer 30

• hypertension
• hyperglycemia, steroid induced diabetes
• weight gain, increased appetite
• puffiness, swelling, edema, water retention
• hyperlipidemia

Question 31

What are the Long-term nutrition related possible side effects of corticosteroids?

Answer 31

• muscle wasting, protein catabolism

- decreased bone mineral density and fractures, calcium wasting

Question 32

What are Nutritional implications of corticosteroids (ex. Prednisone)?

Answer 32

– Low salt/sodium
– Long term use: High calcium/vit D (consider supplements)
– High protein
– May need high potassium, vit A, vit C
– May need diabetic diet (monitor glucose, TG)
– May need heart healthy diet (monitor chol, TG)

Question 33

What are the recommendations when there is risk of malnutrition?

Answer 33

■ Small, frequent, nutrient dense, high kcal meals and snacks
■ 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)

Question 34

What are the supplements that are recommended for COPD patients?

Answer 34

■ ONS (oral nutrition supplements) associated with increased energy intake.
■ Small amounts more frequently may be better tolerated than larger amounts at one time
■ selection of supplements for individuals with COPD should be influenced more by patient preference than the percentage of fat or carbohydrate
– A higher calorie (denser, 2.0 kcals/ml) supplement may be beneficial when intake is reduced.

Question 35

What is the problem with milk in COPD?

Answer 35

■ some individuals perceive increased mucus production after consuming milk and milk products
■ studies report no significant effect of milk and milk products on mucus production
■ More likely the milk coats (produces film) the mucus and/or gives a similar sensation as mucous in the throat, which gives this perception
■ Hot beverage after milk may help reduce the sensation and clear mucous

Question 36

When Does COPD Become Palliative Care/Comfort care (DNR)?

Answer 36

end stage
■ Severe frequent admissions with limited improvement
■ On Maximum therapy
■ Dependant on Oxygen
■ Severe SOB
■ Other co-morbidities (ex. Heart failure)
■ Palliative care: Provide what they would like.

Question 37

What is the link between the heart and the lungs?

Answer 37

■ Both work together to bring oxygen to tissues via circulatory system.
■ In Heart Failure, we saw that the Renin-Angiotensin- Aldosterone system gets activated when the Kidneys detect lower levels of oxygen in the blood.
■ Similarly, the RAAS is also activated when the lungs are not providing adequate gas exchange.
■ In fact, all the major organs work together via hormone release to try to maintain homeostasis
■ Complex compensatory mechanisms

Question 38

What are the special considerations for feeding routes?

Answer 38

■ Intubation for mechanical ventilation
■ Tracheostomy: surgical opening to assist breathing
■ Possible Reasons:
– Bypass obstruction
– Deliver oxygen to lungs when patient can not breathe (using a ventilator)
– Maybe temporary or permanent

Question 39

When is Mechanical ventilation: Intubation via oral route preferred?

Answer 39

■ Can not eat orally because can not safely swallow (airways are open, and epiglottis can’t close).
■ Often these patients are not conscious or heavily sedated
■ Usually on a tube-feeding (enteral nutrition) assuming the GI system is working

Question 40

What is Tracheostomy?

Answer 40

Frequently patients with a tracheostomy require a tube- feeding.
Sometimes swallowing certain textures of foods may be allowed if swallowing has been assessed. Cuff can be inflated.