Nutritional Management of

Pulmonary Diseases
Medical Nutrition
Redario C. Laygo
December 19, 2007

Goal of Medical Nutritional Care

Vicious Cycle
Decline in
Pulmonary Function

Energy Needs Exceed

Energy Intake

Impaired Nutritional
Status

This people cannot prepare their own food, cannot go to the market
and buy their own food a few steps would leave them breathless

They have difficulty even in chewing/swallowing would render
them breathless therefore there is difficulty in taking in the
necessary nutrients further aggravating the imbalance
Pulmonary Diseases
- Associated with malnutrition
- The condition will compromise
- Lung structure (respiratory muscles) and function
- Strength and endurance
- Immune defense (antibodies which need protein for
synthesis)
- Control of breathing important since it is necessary for
oxygen intake

Oxygen necessary for ATP production

2/3 of oxygen taken in is utilized by the mitochondria to
generate ATP
Impact of Malnutrition
- Impaired Pulmonary Function
- Vital capacity
- Minute ventilation
- Efficiency of ventilation
- Altered pulmonary Structure
- Collapse of alveoli important for gas change
- Hypoprotenemia
- Decline in Respiratory Muscle Mass
- Needs actin and myosin
- Strength, endurance and efficiency
- Impaired immunity
- Risk of developing infections

Protein needed to replenish structures in the
tracheobronchial tree
Impact of Lung Disease on Nutritional Status
- 25-50% more energy spend in CLD
- 10% increase in REE with use of salbutamol
- 35% increase in oxygen consumption associated with chest
physical therapy for critically ill, mechanically ventilated patients
Effects of Malnutrition
- Alter lung structure
- Decrease elasticity and function
- Decrease in respiratory muscle mass, strength, endurance and
efficiency
- Alter lung immune defense
- Alter control of breathing
- Increase risk fro pulmonary edema especially in critically ill,
where they are always lying down fluid then goes to
dependent portions of lungs
Effects of Lung Diseases on Nutritional Status
- Increases energy requirement
- Increased work of breathing
- Chronic infection
- Medical treatments
- e.g. chest physiotherapy

- Reduced nutrient intake

- Fluid restriction fluid increases volume of stomach
diaphragm is elevated there is in area for lung
expansion
- Shortness of breath
- Decreased oxygen saturation when eating
- Anorexia
- GIT distress and vomiting
- Additional limitations
- Difficulty of preparing food
- Lack of financial resources
- Impaired feeding skills
- Altered metabolism
Nutritional Care in Respiratory Distress Syndrome
- Goals of nutritional therapy
- Prevent or correct malnutrition
- Prevent overfeeding increase in stomach volume and
in area for lung expansion
- Replace essential fatty acids, carnitine and other nutrients
- Linoleic & Linolenic essential fatty acids
- Linoleic true essential fatty acid
- Carnitine carrier molecule in which fatty acids can
enter mitochondria to be subjected to B-oxidation;
produced by kidney and liver
- 1 gram of fat = 9kcal
- Specific dietary modifications
- Increase fat to add extra calories and give palatability to
diet
- Provide adequate EFA and ADEK
- Caution with TPN-induced CO2 gas
- Weight maintenance: 1-1.2 x BEE
- Anabolism: 1.4-1.6 x BEE
- NPC: 50% glucose and 50% lipid
Nutritional Care in Acute Respiratory Failure
- Goals of nutritional therapy
- Meet energy nutrient requirements
- Preserve LBM
- Maintain fluid and acid-base balance
- Provide nutritional substrates that will not increase CO2

Give small frequent feedings (companionship may help)
- Specific dietary modifications
- Begin feeding ASAP
- Diet: 35-50% CHO and 30-50% lipid cal.
- Adults daily diet of
- 25-35kcal/kg maintenance
- 35-45kcal/kg anabolism to increase weight
- Protein: 2g/kg DBW
- Reduce sodium if with pulmonary edema
- Supplement with vitamins A & C
- Phosphorus if depleted: 2.5-5mg/kg BW
Notes:

Vitamin A
- in the form of retinol phosphate
- boost immune defenses
- for synthesis of protein molecules
- for growth and development

Vitamin D
- for calcium
- synthesized in the kidneys
- calcitriol (active form of vitamin D) needed for calcium
binding
- prevent osteoporosis

Vitamin E
- has antioxidant properties
- in association with selenium

Vitamin K
- for coagulation
- for transcription/translation

Vitamin C
- 75mg/day RDA for Philippines
- Antioxidant
- Not synthesized by the body because humans do not have Lgulunolactone
- Collagen synthesis for praline and lysine to form collagen


Do not give root crops such as kamote or vegetables that produce
gas such as cabbage produce CO2 causes stomach to increase
in volume

Patients with acute respiratory failure have metabolic rate
therefore energy requirements have to be met

Manage drug food interaction if there is
Nutritional Care in Chronic Pulmonary Disease
- Goals of nutritional therapy
- Maintain acceptable weight for height
- Maintain fluid and acid-base balance
- Manage drug-nutrient interactions
- Specific dietary modifications
- Provide high protein/high calorie diet:
- 1.2-1.5g CHON/kg
- BEE x 1.5 for anabolism
- Diet: 40-55% CHO, 30-40% Fat, 15-20% CHON
- Soft diet advised, no gas forming vegetables
- Small, concentrated feeds at intervals
- Supplement with vitamins A, C and B complex
- High fluid intake: 1ml/kcal
- Restrict Na and increase K if with pulmonary edema
- Increase fiber gradually
Notes:

Vitamin B1 (thiamine)
- active form: Thiamine pyrophosphate
- Needed for pyruvate dehydrogenase in the Krebs cycle to
give 12 ATPs/complete cycle
- Also needed for a-ketoglutarate dehydrogenase and transketolase enzyme help cells generate a lot of energy

Vitamin B2 (Roboflavin)
- Needed by FAD & FMN for redox reaction

Vitamin B3 (niacin)

Vitamin B5 (pantothenic acid)
- For Acetyl-CoA production goes into Krebs Cycle

oxidative decarboxylation

product of pyruvate from PDH

Vitamin B6 (pyridoxine)
- Active form: pyridoxal phosphate
- Structural analogue of isoniazid

Vitamin B12 (cobalamin)
- Methionine from homocysteine
- Isomerization of methylmalonyl CoA to succinyl CoA Krebs
cycle intermediate

Pulmo embolism
- Restrict Na
- K
- Fiber
- bulk of stool because they absorb H2O
- Can also absorb bacteria
- Stimulate peristaltic movement
Nutritional Care in Pulmonary Tuberculosis
- Goals of nutritional therapy
- Maintain weight
- Restore Ca levels in serum
- Replace losses from lung bleed
- Promote healing of pulmonary cavities
- Counteract side effects of drugs
- Stimulate appetite
- Prevent dehydration
- Specific dietary modifications
- Well-balanced diet:
- Protein:1.2-1.5g/kg
- Calories: 3000kcal
- Provide sufficient Ca, controlled amounts of vitamin D
- Provide iron and vitamins A & D
- Ensure diet provides vitamin B-complex, especially vitamin
B6
- Fluids : 2 liters unless contraindicated
Notes :

PTB patients have a characteristic stance shoulders raised when
due to loss of a lot of weight

PTB drugs: HRZE too many tablets therefore patients also take
in a lot of water in each intake of medicine induce feeling of fullness

INH should be given with Vitamin B6 (pyridoxine) because INH is
a competitive inhibitor of pyridoxine

Fe especially in patients with bleeding

Fast acetylators if a person can acetylate acetyl CoA to a more
harmful form of drug
Transcribed by: Fred Monteverde
Notes from: Cecile Ong
Charlene Santos
Lecture recorded by: Lala Nieto
Fred Monteverde
Emy Onishi
Cecile Ong
Mitzel Mata
Regina Luz

Mae Olivarez
Lala Nieto
Chok Porciuncula
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