1.mnt for pulmonary diseases


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  • ratio between oxygen  (O2) an organism intakes and  carbon  dioxide (CO2) the organism eliminates
  • Obstruction of the intestine (ileus) due to overly thick meconium, the dark sticky stuff that is normally present in the intestine at birth and, after trypsin and other enzymes from the pancreas have acted on it, is normally passed in the feces after birth.
  • 1.mnt for pulmonary diseases

    1. 1. MEDICAL NUTRITION THERAPY FOR PULMONARY DISEASES Noraishah Mohamed Nor Dept Nutrition Sciences IIUM
    2. 2. DEFINITION <ul><li>Bronchospasm: asthma </li></ul><ul><li>Cor pumonale: heart condition characterized by right ventricular enlargement and failure that results from resistance to passage of blood through the lungs </li></ul><ul><li>Leukotrienes: powerful inflammatory mediators. </li></ul><ul><li>RQ: ratio between oxygen (O2) an organism intakes and carbon dioxide (CO2) the organism eliminates </li></ul><ul><li>Dyspnea: Dyspnea is defined as abnormal breathing and usually refers to the uncomfortable feeling of breathlessness. Also known as shortness of breath </li></ul>
    4. 5. <ul><li>The respiratory system is situated in the thorax, and is responsible for gaseous exchange. </li></ul><ul><li>Air is taken in via the upper airways (the nasal cavity, pharynx and larynx) through the lower airways (trachea, primary bronchi and bronchial tree) and into the small bronchioles and alveoli within the lung tissue.  </li></ul><ul><li>The lungs are divided into  lobes ; </li></ul><ul><ul><li>The left lung is composed of the  upper lobe , the  lower lobe  and the  lingula  (a small remnant next to the apex of the heart), the right lung is composed of the  upper , the  middle  and the  lower  lobes. </li></ul></ul>
    5. 6. MECHANICS OF BREATHING <ul><li>To take a breath in, the  external intercostal muscles  contract, moving the ribcage up and out. </li></ul><ul><li>The  diaphragm  moves down at the same time, creating negative pressure within the thorax. The lungs are held to the thoracic wall by the pleural membranes , and so expand outwards as well. </li></ul><ul><li>This creates negative pressure within the lungs, and so air rushes in through the upper and lower airways. </li></ul>
    6. 7. <ul><li>Expiration is mainly due to the natural elasticity of the lungs, which tend to collapse if they are not held against the thoracic wall. </li></ul><ul><li>This is the mechanism behind lung collapse if there is air in the pleural space ( pneumothorax ). </li></ul>
    7. 8. PHYSIOLOGY OF GAS EXCHANGE <ul><li>Each branch of the bronchial tree eventually sub-divides to form very narrow terminal bronchioles, which end in the  alveoli . </li></ul><ul><li>There are many millions of alveloi in each lung, and these are the areas responsible for gaseous exchange, presenting a massive surface area for exchange to occur over. </li></ul><ul><li>Each alveolus is very closely associated with a network of capillaries containing deoxygenated blood from the pulmonary artery. </li></ul>
    8. 9. <ul><li>The capillary and alveolar walls are very thin, allowing rapid exchange of gases by  passive diffusion along concentration gradients .  </li></ul><ul><li>CO 2  moves  into  the alveolus as the concentration is much lower in the alveolus than in the blood, and O 2  moves  out of  the alveolus as the continuous flow of blood through the capillaries prevents saturation of the blood with O 2  and allows maximal transfer across the membrane. </li></ul>
    9. 10. IMPACT OF RESPIRATORY SYSTEM DISEASES ON NUTRITIONAL STATUS <ul><li>Pulmonary disease substantially increase energy requirements. </li></ul><ul><li>The complication of pulmonary disease or their tx can cause difficulty in food intake and digestion. </li></ul><ul><li>the absorption, circulation, cellular utilization, storage, and excretion of most nutrient problematic </li></ul>
    10. 11. ADVERSE EFFECTS OF LUNG DISEASE ON NUTRITIONAL STATUS <ul><li>Increased energy expenditure </li></ul><ul><ul><li>Increased work of breathing </li></ul></ul><ul><ul><li>Chronic infection </li></ul></ul><ul><ul><li>Medical treatments (e.g. bronchodilators, chest physical therapy </li></ul></ul>
    11. 12. <ul><li>Reduced intake </li></ul><ul><ul><li>Fluid restriction </li></ul></ul><ul><ul><li>Shortness of breath </li></ul></ul><ul><ul><li>Decreased oxygen saturation when eating </li></ul></ul><ul><ul><li>Anorexia due to chronic disease </li></ul></ul><ul><ul><li>Gastrointestinal distress and vomiting </li></ul></ul><ul><li>Additional limitations </li></ul><ul><ul><li>Difficulty preparing food due to fatigue </li></ul></ul><ul><ul><li>Lack of financial resources </li></ul></ul><ul><ul><li>Impaired feeding skills (for infants and children) </li></ul></ul><ul><ul><li>Altered metabolism </li></ul></ul>
    13. 14. ACUTE PULMONARY DISORDERS <ul><li>Pulmonary aspiration </li></ul><ul><li>Pneumonia </li></ul><ul><li>Tuberculosis </li></ul><ul><li>Cancer of the lung </li></ul><ul><li>Acute respiratory distress syndrome </li></ul><ul><li>Pulmonary failure </li></ul>
    14. 15. CHRONIC PULMONARY DISORDERS <ul><li>Bronchopulmonary dysplasia </li></ul><ul><li>Cystic fibrosis </li></ul><ul><li>Tuberculosis </li></ul><ul><li>Bronchial asthma </li></ul><ul><li>Chronic obstructive pulmonary disease (COPD) </li></ul>
    15. 16. PULMONARY CONDITIONS WITH NUTRITIONAL IMPLICATIONS Neonate Bronchopulmonary displasia (BPD) Obstruction <ul><li>Cystic fibrosis (CF) </li></ul><ul><li>Chronic obstructive pulmonary disease (COPD) </li></ul><ul><ul><li>Emphysema </li></ul></ul><ul><ul><li>Chronic bronchitis </li></ul></ul><ul><ul><li>Asthma </li></ul></ul>Tumor Lung cancer
    16. 17. Infection Pneumonia Tuberculosis (TB) Respiratory Failure Acute respiratory failure Lung transplantation Cardiovascular Pulmonary edema
    17. 18. PULMONARY ASPIRATION <ul><li>Movement of food or fluid (oral/ETF) into the lung, can result in pneumonia or even death. </li></ul><ul><li>Proper body positioning when eating is essential </li></ul><ul><li>Increased risk in: </li></ul><ul><ul><li>Infant, toddlers, older adult, person with upper GIT problem, neurologic or muscular abnormalities. </li></ul></ul><ul><li>Symptoms include dyspnea, tachycardia, wheezing, rales, anxiety, agitation, cyanosis </li></ul>
    18. 19. ASTHMA <ul><li>Def: Chronic inflammatory disorder of the airway involving many cells and cellular elements such as mast cell, eosinophil etc. </li></ul><ul><li>It is a condition of bronchial hyper-responsiveness, and airway inflammation, leading to air flow obstruction. </li></ul><ul><li>The syndrome appears to result from complex interactions among genetic, immunologic and environmental factors. </li></ul>
    19. 20. <ul><li>This inflammation causes recurrent episode of wheezing, breathlessness, chest tightness, and coughing usually in the early morning or late night. </li></ul><ul><li>Pathopysiology: </li></ul><ul><ul><li>When asthma occur, bronchi and bronchioles respond to the stimuli by contraction of smooth muscle (bronchoconstriction). </li></ul></ul><ul><ul><li>The mucosa is inflamed and edematous with increased production of mucus. </li></ul></ul><ul><ul><li>This result in partial or total air way obstruction. </li></ul></ul>
    20. 22. MEDICAL NUTRITION THERAPY (MNT) <ul><li>Asthma prevalence increase in obese individual </li></ul><ul><ul><li>Provide healthy diet and maintain healthy weight </li></ul></ul><ul><li>Food and individual nutrients are being studies: </li></ul><ul><ul><li>Omega- 3 & Omega -6 : role in reducing the production of bronchoconstrictive leukotrienes. </li></ul></ul><ul><ul><li>Antioxidant : role in protecting the airway tissue from oxidative stress. </li></ul></ul><ul><ul><li>Mg : role as smooth muscle relaxant and anti-inflammatory agent </li></ul></ul><ul><ul><li>Methylxanthines (caffeine): role as bronchodialators </li></ul></ul>
    21. 23. <ul><li>Food sensitivities may be triggers for asthmatic episodes (sulfites, shrimp, herbs) but not the most common causes. </li></ul><ul><li>Some studies shows: breast feeding demonstrate a protective effects against asthma development </li></ul><ul><li>Tx: moving any items from the pt’s environment that are known to be the triggers </li></ul><ul><li>If this don’t works: use medication which usually cause  dry mouth, throat irritation, nausea, vomiting & diarrhea. </li></ul>
    22. 24. BRONCHOPULMONARY DYSPLASIA (BPD) <ul><li>Chronic lung condition in newborns that often follows respiratory distress syndrome (RDS) and treatment with oxygen </li></ul><ul><li>Characterized by pulmonary inflammation, & impaired growth and development of the alveoli </li></ul><ul><li>Occurs most frequently in infants who are premature or low birth weight </li></ul>
    23. 25. <ul><li>Sign & symptoms: </li></ul><ul><ul><li>Hypercapnea (CO2 retention) </li></ul></ul><ul><ul><li>Tachypnea (rapid breathing) </li></ul></ul><ul><ul><li>Wheezing </li></ul></ul><ul><ul><li>Dyspnea (symptom of breathlessness) </li></ul></ul><ul><ul><li>Recurrent respiratory infections </li></ul></ul><ul><ul><li>Cor pulmonale (right ventricular enlargement of the heart) </li></ul></ul>
    24. 26. <ul><li>Growth Failure in BPD due to: </li></ul><ul><ul><li>Increased energy needs </li></ul></ul><ul><ul><li>Inadequate dietary intake </li></ul></ul><ul><ul><li>Gastroesophageal reflux </li></ul></ul><ul><ul><li>Emotional deprivation </li></ul></ul><ul><ul><li>Chronic hypoxia (reduce the amount of oxygen available in the blood ) </li></ul></ul>
    25. 27. MNT <ul><li>Meet nutritional needs (appropriate with wt & length) </li></ul><ul><li>Promote linear growth </li></ul><ul><li>Develop age-appropriate feeding skills </li></ul><ul><li>Maintain fluid balance </li></ul>
    26. 28. <ul><li>The Energy needs in infants with BPD is 15-25% higher than same age healthy, normal infants (Denne, 2001) </li></ul><ul><li>Estimated energy needs of 120 – 130 kcal/kg – for appropriate growth. </li></ul><ul><li>Energy needs 130 -160 kcal/day for those with increase metabolic demand </li></ul><ul><li>Babies with growth failure may have needs 50% higher </li></ul>
    27. 29. <ul><li>Protein: within advised range for infants of comparable post- conceptional age </li></ul><ul><li>As energy density of the diet is increased by the addition of fat and carbohydrate, protein should still provide 7% or more of total kcals </li></ul><ul><li>Protein intake of 3 – 4 g/kg have been recommended (Carlson 2004) </li></ul><ul><li>Intake > 4g/kg should be avoided  risk to develop acidosis in infant with immature kidney. </li></ul>
    28. 30. <ul><li>Fat and carbohydrate should be added to formula only after it has been concentrated to 24 kcal/oz to keep protein high enough </li></ul><ul><li>Fat provides EFA and energy when tolerance for fluid and carbohydrate is limited </li></ul><ul><li>Excess CHO increases respiratory quotient (RQ) and CO2 output </li></ul>
    29. 31. MINERALS NEEDS <ul><li>Lack of mineral stores as a result of prematurity (iron, zinc, calcium) </li></ul><ul><li>Growth delay </li></ul><ul><li>Medications: diuretics, bronchodilators, antibiotics, cardiac antiarrhythmics, corticosteroids associated with loss of minerals including chloride, potassium, calcium </li></ul>
    30. 32. VITAMINS NEEDS <ul><li>Interest in antioxidants, including vitamin A for role in developing epithelial cells of the respiratory tract </li></ul><ul><li>Provide intake based on the DRI, including total energy, to promote catch up growth </li></ul>
    31. 33. FLUID NEEDS <ul><li>Infants with BPD may require fluid restriction, sodium restriction, and long term treatment with diuretics </li></ul><ul><li>Use of parenteral lipids or calorically dense enteral feeds may help the infant meet energy needs </li></ul>
    32. 34. FEEDING STRATEGIES IN BPD <ul><li>Calorically dense formulas or boosted breast milk (monitor fluid status and urinary output) </li></ul><ul><li>Small, frequent feedings </li></ul><ul><li>Use of a soft nipple </li></ul><ul><li>Nasogastric or gastrostomy tube feedings </li></ul>
    33. 35. CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) <ul><li>Characterized by airway obstruction </li></ul><ul><li>Types of COPD: </li></ul><ul><ul><li>Emphysema (type 1): </li></ul></ul><ul><ul><ul><li>abnormal, permanent enlargement of alveoli, accompanied by destruction of their walls without obvious fibrosis </li></ul></ul></ul><ul><ul><ul><li>Cor pulmonale developes late in the course of disease </li></ul></ul></ul><ul><ul><ul><li>patients are thin, often cachectic; older, mild hypoxia, normal hematocrits </li></ul></ul></ul>
    34. 36. <ul><ul><li>Chronic bronchitis (type 2): </li></ul></ul><ul><ul><ul><li>chronic, productive cough with inflammation of one or more of the bronchi and secondary changes in lung tissue </li></ul></ul></ul><ul><ul><ul><li>Cor pulmonale developes early in the course of disease </li></ul></ul></ul><ul><ul><ul><li>of normal weight; often overweight; hypoxia; high hematocrit </li></ul></ul></ul><ul><ul><ul><li>Decrease air flow rate (FEV) </li></ul></ul></ul>
    35. 37. COPD SEVERITY SCALE We've included this chart so that you will know what your doctor means when he or she tells you how severe your COPD is. Make sure to have your condition explained clearly to you, and find out everything you can about how to keep from progressing higher on this scale. 0: At Risk This classification comes before major damage is really done. Your doctor has determined that you have the risk factors associated with developing COPD later in life, and he or she will probably recommend lifestyle changes and regular testing. • Normal spirometry at every physician visit • Symptoms (cough, sputum production) may be present, but not yet serious I: Mild COPD In this case, spirometry has shown mild airflow limitations due to chronic cough, mucus production, and the beginning of damage to your lungs. You may not be aware of your symptoms. Some characteristics of this stage include: • FEV1/FVC < 70% • FEV1 >= 80% predicted • Starting to suffer from chronic symptoms (cough, sputum productio)
    36. 38. II: Moderate COPD At this stage, your airflow is getting worse. You have very noticeable symptoms, and dyspnea occurs with everyday exertion. This is when most people go to their doctor for the first time. Characteristics include: • FEV1/FVC < 70% • 50% <= FEV1 < 80% predicted   • Chronic symptoms (cough, sputum production) III: Severe COPD Very limited airflow. Dyspnea occurs after minimal exertion, to the point where even small tasks like leaving the house or going upstairs are a major issue. Characteristics include: • FEV1/FVC < 70% • 30% <= FEV1 < 50% predicted • Chronic symptoms (cough, sputum production)
    37. 39. IV: Very Severe COPD At this stage, complications such as respiratory failure and heart failure begin to develop. Quality of life is extremely impaired and the symptoms become life threatening. Characteristics include: • FEV1/FVC < 70% • FEV1/FVC <30% predicted or FEV1< 50% predicted plus chronic respiratory failure • Classification based on post-bronchodilator FEV1 • Respiratory Failure: arterial partial pressure of oxygen PaO2 less than 60mmHg with or without PaCO2 greater than 50mmHg while breathing at sea level FEV stands for Forced Expiratory Volume , or the amount of air you can blow out of your lungs in one second. FVC stands for Forced Vital Capacity , or the total amount of air you can blow out. FEV 1 /FVC   is the ratio that compares the amount you can blow out quickly to the total amount your lungs can blow out.
    38. 40. MNT ASSESSMENT <ul><li>Fluid balance and requirements </li></ul><ul><li>Energy needs </li></ul><ul><li>Food intake (decreased intake common) </li></ul><ul><li>Morning headache and confusion from hypercapnia (excessive CO2 in the blood) </li></ul><ul><li>Fat free mass </li></ul><ul><li>Food drug interactions </li></ul><ul><li>Fatigue </li></ul><ul><li>Anorexia </li></ul><ul><li>Difficulty chewing/swallowing because of dyspnea </li></ul><ul><li>Impaired peristalsis secondary to lack of oxygen to the GI tract </li></ul><ul><li>Underweight patients have the highest morbidity/mortality </li></ul>
    39. 41. MNT <ul><li>Malnutrition occur in 24 – 35% with moderate to severe COPD pt, with average wt loss of 5 to 10 % of initial body weight </li></ul><ul><li>Higher BEE due to breathing difficulties and inflammation hypermetabolism. </li></ul><ul><li>Energy intake of 125 – 156% (average 140%) above BEE </li></ul><ul><li>protein 1.2 – 1.7 g/kg (average 1.2 g/kg) enough to avoid protein losses. </li></ul>
    40. 42. <ul><li>Malnourished pt need higher energy & protein to provide for repletion </li></ul><ul><li>Do not over feed pt,  may increase CO2 production which can complicate the ventilation </li></ul><ul><li>The production of excess CO2 occur when pt overfed >1.5 x REE </li></ul><ul><li>Balanced ratio of macro nutrients: </li></ul><ul><ul><li>Protein : 15 – 20% (1.2 – 1.7 g/kg) </li></ul></ul><ul><ul><li>Fat : 30 – 45 % </li></ul></ul><ul><ul><li>CHO: 40 – 55 % </li></ul></ul><ul><li>Maintain appropriate RQ </li></ul><ul><li>Address other underlying diseases (diabetes, heart disease) </li></ul>
    41. 43. <ul><li>Vitamins: intakes should at least meet the DRI </li></ul><ul><li>Smokers may need more vitamin C (+16-32 mg) depending on cigarette use </li></ul><ul><li>Minerals: meet DRIs and monitor phosphorus and magnesium in patients at risk for refeeding during aggressive nutrition support </li></ul>
    42. 44. <ul><li>GI motility: adequate exercise, fluids, dietary fiber </li></ul><ul><li>Abdominal bloating: limit foods associated with gas formation </li></ul><ul><li>Fatigue: resting before meals, eating nutrient-dense foods, arrange assistance with shopping and meal preparation </li></ul>
    43. 45. <ul><li>Suggest that patient </li></ul><ul><ul><li>Use oxygen at mealtimes </li></ul></ul><ul><ul><li>Eat slowly </li></ul></ul><ul><ul><li>Chew foods well </li></ul></ul><ul><ul><li>Engage in social interaction at mealtime </li></ul></ul><ul><ul><li>Coordinate swallowing with breathing </li></ul></ul><ul><ul><li>Use upright posture to reduce risk of aspiration </li></ul></ul><ul><li>Oral supplements </li></ul><ul><li>Nocturnal or supplemental tube feedings </li></ul><ul><li>Specialized pulmonary products generally not necessary </li></ul>
    44. 46. FOOD DRUG INTERACTIONS <ul><li>Aminoglycosides lower serum Mg ++ —may need to replace </li></ul><ul><li>Prednisone—monitor nitrogen, Ca ++ , serum glucose, etc. </li></ul>
    45. 47. CYSTIC FIBROSIS (CF) <ul><li>Inherited autosomal recessive disorder </li></ul><ul><li>CF incidence of 1:2500 live births </li></ul><ul><li>Survival is improving; median age of patients has exceeded 30 years </li></ul><ul><li>Epithelial cells and exocrine glands secrete abnormal mucus (thick) </li></ul><ul><li>Affects respiratory tract, sweat, salivary, intestine, pancreas, liver, reproductive tract </li></ul>
    46. 49. DIAGNOSIS OF CYSTIC FIBROSIS <ul><li>Neonatal screening provides opportunity to prevent malnutrition in CF infants </li></ul><ul><li>Sweat test (Na and Cl >60 mEq/L) </li></ul><ul><li>Chronic lung disease </li></ul><ul><li>Failure to thrive </li></ul><ul><li>Malabsorption </li></ul><ul><li>Family history </li></ul>
    47. 50. NUTRITIONAL IMPLICATIONS OF CF <ul><li>Infants born with meconium ileus are highly likely to have CF </li></ul><ul><li>85% of persons with CF have pancreatic insufficiency </li></ul><ul><li>Plugs of mucus reduce the digestive enzymes released from the pancreas causing maldigestion of food and malabsorption of nutrients </li></ul>
    48. 51. <ul><li>Decreased bicarbonate secretion reduces digestive enzyme activity </li></ul><ul><li>Decreased bile acid reabsorption contributes to fat malabsorption </li></ul><ul><li>Excessive mucus lining the GI tract prevents nutrient absorption by the microvilli </li></ul>
    49. 52. GASTROINTESTINAL COMPLICATIONS <ul><li>Bulky, foul-smelling stools </li></ul><ul><li>Cramping and intestinal obstruction </li></ul><ul><li>Rectal prolapse </li></ul><ul><li>Liver involvement </li></ul><ul><li>Pancreatic damage causes impaired glucose tolerance (50% of adults with CF) and development of diabetes (15% of adults with CF) </li></ul>
    50. 53. COMMON TREATMENTS <ul><li>Pancreatic enzyme replacement </li></ul><ul><li>Adjust macronutrients for symptoms </li></ul><ul><li>Nutrients for growth </li></ul><ul><li>Meconium ileus equivalent: intestinal obstruction (enzymes, fiber, fluids, exercise, stool softeners) </li></ul>
    51. 54. <ul><li>Pancreatic Enzyme Replacement </li></ul><ul><ul><li>Introduced in the early 1980s </li></ul></ul><ul><ul><li>Enteric-coated enzyme microspheres withstand acidic environment of the stomach </li></ul></ul><ul><ul><li>Release enzymes in the duodenum, where they digest protein, fat and carbohydrate </li></ul></ul>
    52. 55. NUTRITIONAL CARE GOALS <ul><li>Control malabsorption </li></ul><ul><li>Provide adequate nutrients for growth or maintain weight for height or pulmonary function </li></ul><ul><li>Prevent nutritional deficiencies </li></ul>
    53. 56. MNT <ul><li>Estimation of Energy Req: </li></ul><ul><ul><li>Use WHO equations to estimate BMR </li></ul></ul><ul><ul><li>Multiply by activity coefficient + disease coefficient </li></ul></ul><ul><ul><li>TEE – BMR X (AC + DC) </li></ul></ul><ul><ul><li>Disease coefficient is based on lung function </li></ul></ul><ul><ul><li>Normal lung function = 0.0 </li></ul></ul><ul><ul><li>Moderate lung disease = 0.2 </li></ul></ul><ul><ul><ul><li>FEV1 40-79% of that predicted </li></ul></ul></ul><ul><ul><li>Severe lung disease = 0.3 </li></ul></ul><ul><ul><ul><li>FEV1 <40% of that predicted </li></ul></ul></ul>
    54. 57. <ul><li>Example </li></ul><ul><ul><li>Male patient 22 years old, weight 54 kg, relatively sedentary </li></ul></ul><ul><ul><li>FEV1 is 60% of predicted (moderate lung disease) </li></ul></ul><ul><ul><li>TEE = BMR X (1.5 + 0.2) </li></ul></ul><ul><ul><li>TEE = [(15.3 (54) + 679] X 1.7 </li></ul></ul><ul><ul><li>TEE = 2559 kcals </li></ul></ul>
    55. 58. <ul><li>In children energy req should be based on the wt gain and growth. </li></ul><ul><li>Energy need for CF children without ventilation are comparable to healthy children (100 – 110% of RDA). </li></ul><ul><li>In case of significant lung disease, malabsorption, ER increase 120 -150% of RDA </li></ul>
    56. 59. <ul><li>Protein Req: </li></ul><ul><ul><li>Protein needs are increased in CF due to malabsorption </li></ul></ul><ul><ul><li>If energy needs are met, protein needs are usually met by following 15-20% protein or use RDA </li></ul></ul>
    57. 60. <ul><li>Fat Req: </li></ul><ul><ul><li>Fat intake 35-40% of calories (in fat malabsorption), as tolerated </li></ul></ul><ul><ul><li>Helps provide required energy, essential fatty acids and fat-soluble vitamins </li></ul></ul><ul><ul><li>Limits volume of food needed to meet energy demands and improves palatability of the diet </li></ul></ul><ul><ul><li>EFA deficiency sometimes occurs in CF patients despite intake and pancreatic enzymes </li></ul></ul><ul><ul><li>Fat restriction is not recommended  important energy sources </li></ul></ul><ul><ul><li>Fat used  MCT oil </li></ul></ul>
    58. 61. <ul><li>CHO req: </li></ul><ul><ul><li>Eventually intake may need to be modified if glucose intolerance develops </li></ul></ul><ul><ul><li>Some patients develop lactose intolerance </li></ul></ul><ul><li>Vitamins req: </li></ul><ul><ul><li>With pancreatic enzymes, water soluble vitamins usually adequately absorbed with daily multivitamin </li></ul></ul><ul><ul><li>Will need high potency supplementation of fat soluble vitamins (A, D, K, E) </li></ul></ul>
    59. 62. FEEDING STRATEGIES: INFANTS <ul><li>Breast feeding with supplements of high-calorie formulas and pancreatic enzymes </li></ul><ul><li>Calorie dense infant formulas (20-27 kcals/oz) with enzymes </li></ul><ul><li>Protein hydrolysate formulas with MCT oil if needed </li></ul>
    60. 63. FEEDING STRATEGIES: CHILDREN AND ADULTS <ul><li>Regular mealtimes </li></ul><ul><li>Large portions </li></ul><ul><li>Extra snacks </li></ul><ul><li>Nutrient-dense foods </li></ul><ul><li>Nocturnal enteral feedings </li></ul><ul><ul><li>Intact or hydrolyzed formulas </li></ul></ul><ul><ul><li>Add enzyme powder to feeding or take before and during </li></ul></ul>
    61. 64. PNEUMONIA <ul><li>Inflammation (infection) of the lung usually caused by bacteria, viruses or fungi. </li></ul><ul><ul><li>Hospital acquired pneumonia (HAP) </li></ul></ul><ul><ul><li>Community acquired pneumonia (CAP) </li></ul></ul><ul><li>The infection causes deterioration of lung fx resulting in fluid accumulation and breathing difficulties. </li></ul><ul><li>Aspiration pneumonia: another common causes for dev of pneumonia is aspiration of inhaled materials (saliva, nasal secretion, bacteria, foods) in to the air ways. </li></ul><ul><ul><li>It happened when the material causes inflammatory response in the lung </li></ul></ul>
    62. 65. NUTRITION IMPLICATION <ul><li>Pt admitted to the hospital due to CAP, most important risk factor associated to mortality  low serum albumin (<3.0 g/dl) </li></ul><ul><li>The depress alb is associated to the inflammation response rather than malnutrition. </li></ul><ul><li>Other indices of poor NS associate to death are low triceps skinfold (TSF) and low BMI. </li></ul>
    63. 66. PATIENTS WITH TRACHEOSTOMIES <ul><li>Tracheostomy is a surgical opening made in trachea to assist breathing. </li></ul><ul><li>It is done to: </li></ul><ul><ul><li>To by pass an obstruction in trachea </li></ul></ul><ul><ul><li>To clean and remove secretion from trachea </li></ul></ul><ul><ul><li>More easily & safely deliver O2 to lung </li></ul></ul><ul><li>Complication: </li></ul><ul><ul><li>Difficult in swallowing </li></ul></ul><ul><ul><li>Inability to speak normally </li></ul></ul><ul><li>High risk for pneumonia if pt is on ventilation  tube feeding </li></ul><ul><li>When it is safe for pt to eat orally, dietitian need to work closely with speech pathologist to determined the constituency of food </li></ul>
    64. 67. RESPIRATORY FAILURE <ul><li>Occur when the respiratory system is no longer able to perform its normal fx. </li></ul><ul><li>It result from long standing chronic lung disease like COPD, CF or as a result of an acute insult (abuse) to the lung such as acute respiratory distress syndrome (ARDS). </li></ul><ul><li>Categories of ARDS: </li></ul><ul><ul><li>Directly cause injured to the lung eg. Pneumonia, aspiration or inhalation injury </li></ul></ul><ul><ul><li>Indirectly cause injury precipitated by event outside the lung e.g. sepsis, trauma, or pancreatitis. </li></ul></ul>
    65. 68. MNT <ul><li>Energy req is based on the underlying diseases (often hypermetabolic)  1.2 – 1.4 x BEE </li></ul><ul><li>REMEMBER do not over feed the pt  increase CO2 production </li></ul><ul><ul><li>Increase ventilatory demand associated with overfeeding; excess glucose administration (>5 mg/kg per min) and excess EI </li></ul></ul><ul><ul><li>The provision 25 kcal/kg (130% of BEE) appears to be adequate to most pt (Cerra 2002) </li></ul></ul><ul><ul><li>Fluid balanced should be monitor closely </li></ul></ul><ul><li>Protein req: 1.2 – 1.5 g/kg (to promote nitrogen retention without being excessive </li></ul><ul><li>ARDS  pulmonary edema, the use of fluid restricted enteral formulation (1.5 – 2 kcal/cc)may be helpful, for those need for fluid restiction </li></ul>
    66. 69. <ul><li>ARDS associate with production of oxygen free radical and inflammatory mediators, recent study shows: </li></ul><ul><ul><li>EPA in fish oil and GLA in borage oil can reduce the severity of inflammatory injury by altering the availability of AA in phospholipids. </li></ul></ul><ul><ul><li>High level of antioxidant: α -tocopherol, β -carotene and vit C at higher level than DRI  increase serum α -tocopherol, β -carotene & prevent further oxidative damage. </li></ul></ul><ul><ul><li>Phosphate is essential for optimal pulmonary fx and normal diaphragm contraction  hypophosphatemia increase hospital stay and dependence to ventilation. Need to monitor phosphate and supplementation should be initiated in hypophosphatemia </li></ul></ul>
    67. 70. ACUTE LUNG INJURY (ALI) <ul><li>Causes </li></ul><ul><ul><li>Aspiration of gastric contents or inhalation of toxic substances </li></ul></ul><ul><ul><li>High inspired oxygen </li></ul></ul><ul><ul><li>Drugs </li></ul></ul><ul><ul><li>Pneumonitis, pulmonary contusions, radiation </li></ul></ul><ul><ul><li>Sepsis syndrome, multisystem trauma, shock, ,pancreatitis, pulmonary embolism </li></ul></ul>
    68. 71. NUTRITION ASSESSMENT IN ALI AND ARDS <ul><li>Indirect calorimetry best tool to determine energy needs in critically ill patients </li></ul><ul><li>In absence of calorimetry, use predictive equations with stress factors </li></ul><ul><li>Avoid overfeeding </li></ul><ul><li>Patients may need high calorie density feedings to achieve fluid balance </li></ul>
    69. 72. TUBERCULOSIS <ul><li>TB is making a comeback </li></ul><ul><li>Many patients are developing drug-resistant TB </li></ul><ul><li>Nutritional factors that increase risk of TB: </li></ul><ul><ul><li>Protein-energy malnutrition: affects the immune system; debate whether it is a cause or consequence of the disease </li></ul></ul><ul><ul><li>Micronutrient deficiencies that affect immune function (vitamin D, A, C, iron, zinc) </li></ul></ul>
    70. 73. <ul><li>Nutritional consequences: </li></ul><ul><ul><li>Increased energy expenditure </li></ul></ul><ul><ul><li>Loss of appetite and body weight </li></ul></ul><ul><ul><li>Increase in protein catabolism leading to muscle breakdown </li></ul></ul><ul><ul><li>Malabsorption causing diarrhea, loss of fluids, electrolytes </li></ul></ul>
    71. 74. MNT <ul><li>Energy: 35-40 kcals/kg of ideal body weight </li></ul><ul><li>Protein: 1.2-1.5 grams/kg body weight, or 15% of energy or 75-100 grams/day </li></ul><ul><li>Multivitamin-mineral supplement at 100-150% DRI </li></ul>
    72. 75. THANK YOU…. <ul><li>Questions??? </li></ul>