NUTRITION & RESPIRATORY

DISEASE

NUTRITION DEPARTMENT
FK-UNHAS
STANDAR KOMPETENSI DOKTER
INDONESIA 2012
NO DISEASE LEVEL

1 PPOK 3B

2. Tuberkulosis paru tanpa komplikasi 4A

3. ARDS 3B

4. Edema paru 3B
Outline
• Malnutrition and respiratory disease (etiology and
mechanism)
• Nutritional management in respiratory disease
• Respiratory quotient
References:
• Guenter WJ. Jensen G. Malone A. Schoefield M. The Academy Malnutrition Work Group. ASPEN
Malnutrition Task. Force and The ASPEN Board of Directors. Consensus Statement of the Academy
of Nutrition and Dietetics: Characteristic Recommended for the Identification and Documentation of
Adult malnutrition. Acad Nutr. Diet. 2012; 112: 730 -38
• Elia, M. Screening for malnutrition: A multidisiplinary responsibility. Development and use of the
malnutrition universal screening tool (MUST) for adults, BAPEN. 2003.
• Krause’s Food & Nutrition Therapy. Ed.12.Canada.Saunders Company. 1016 – 991
• Stumo S.E. 2002. Chronic obstructive pulmonary diseases (emphysema and chronic bronchitis).
Dalam : Nutrition and diagnosis related care Baltimore : Lippincott Williams &Wilkins . 191-193
• Laura E. Newton, MA., RD. and Sarah L. Morgan, MD., MS., RD. 2006.Pulmonary Disease. Dalam :
Douglas C. Heimburger, MD, Ms., Jamy D. Ard, MD., Handbook of Clinical Nutrition. Ed. 4.
Philadelphia. MOSBY. ELSEVIER. 503-509.
• S.D. Ankera, M. Johnb, P.U. Pedersenc, et al. 2006. ESPEN Guidelines on Enteral
Nutrition:Cardiology and Pulmunology. Clinical Nutrition Vol.25, 311-318
• S.D. Anker, A. Laviano, G. Filippatos, M. John, et.al. 2009. ESPEN guideline on Parenteral Nutrition
: on Cardiology and Pulmunology. Clinical Nutrition Vol., 28, 455-460
Learning outcome (general)
Understand :
• Nutrition metabolism, pathophysiology, malnutrition in
respiratory disease
• Nutrition management in respiratory diseases
Able to :
• Aplicate the knowledge to establish nutrition diagnosis
and therapy
Specific learning outcome
Explain :
• Nutrition metabolism in respiratory diseases
• Etiology of malnutrition in respiratory diseases
• Pathophysiology of malnutrition in respiratory diseases
• Effect of malnutrition in respiratory diseases

Explain and aplicate nutrition therapy in respiratory

diseases (Tuberculosis, COPD, ARDS, Pulmonary
edema)
Nutritional problems in respiratory diseases

• Central hypoxia dan hypercapnia

• Respiratory muscle
• Lung tissue
• Imunity
Nutrition composition and respiratory
consideration :
• Metabolic rate
• Oxygen consumption
• Carbon dioxide production

Hypofosfatemia  ventilation
Nutrition composition and ventilation rate

 Ability to increase ventilation as a respons to

hypoxia dan hypercapnia

 Related to metabolic rate, increase of

metabolism  hypoxia  ventilation ↑
• Underfed patient (given 5% dextrose) 
ventilation respond to hypoxia ↓ disturbance of
adequate ventilation
• Normal condition  adequate nutrition

inadequate nutrition  RISKY

Who is given nutrition intervention?
• BMI < 21
• Weight loss > 10% in 6 weeks, >5% in 1 months
• Fat free mass depletion
Effect of nutrition intervention in respiratory
function
• Weight loss  decrease diaphragm and respiratory
muscle
• Emphysema  shorthen muscle fiber  decrease
deficiency
• Malnutrition  catabolism of diaphragm, intercostal
muscle  energy  ↓ inspiration capacity
• Infection, inflammation, and ↓ protein intake↓ albumin
plasma  ↓ oncotic pressure  pulmonal edema
• Malnutrition  ↓ surfactan production  alveoli collaps
Principle of nutrition intervention
• Nutrition assesment
• Nutrition requirement (underfeeding vs overfeeding)
• Protein balance
• Fluid and electrolyte
• High fat diet – low carbo --hypercapnia?
• PUFA/Omega 3 as anti-inflammation agent
Nutrition requirement
• Critically ill 25-30 kkal/day
• Harris benedict equation
• Indirect calorimetric
• Underfeeding and overfeeding
• Calorie total: 1,1 – 1,4 x BMR
Metabolism, O2 consumption, CO2 production

• Abnormal gas exchange  hyposemia and/or

hypercapnia
• Total energy and macronutrient composition influence
production on CO2 and consumption of O2
Asupan energi
• Overfeeding in acute respiratory disorder  ↑
metabolic rate O2 & CO2
• High fat synthesis  produksi CO2 berlebihan
• RQ (respiratory quotient) : ratio of CO2 production to
O2 consumption
• RQ Carbohydrate = 1.0
• RQ Protein = 0,8
• RQ Fat = 0,7
• RQ  energy formed by carbohydrate affect
the number of CO2 production

• Subtitution of carbohydrate into fat will

decrease the production of CO2; Avoid the use
of mechanic ventilation and enhance the
weaning from ventilator
EBM high fat-low CHO diet
• High fat diet produce dyspnue more than high CHO diet,
Vermeeren et all, 2001
• Stable COPD’s patient, no additional advantage of
disease specific formula. ESPEN enteral, 2006
• Frequent smaller amounts of ONS are preferred to avoid
postprandial dyspnea and satiety and to improve
compliance. Vermeeren et all, 2001, ESPEN enteral 2006
EBM High fat-low CHO diet
• Patient with stable COPD, glucose-based PN increase
respiratory CO2 load, PN composition should be
orientated towards lipids as energy source. ESPEN
parenteral, 2009
High Fat-Low CHO diet
• Acute respiratory disease
• Hypercapnia
• Nonhypercapnia patient : CHO 50-60%, Fat 20-30%, Protein 15-
20%
• Hypercapnia patient: CHO 25-30%, Fat 50-55%, protein 15-20%
Nitrogen Balance
• 0.8 – 1.5 gr/kgbb/day
Fluid
• Fluid balance
• Restriction  pulmonary edema
Micronutrien
• K, Ca, PO4, Mg should be provided in adequate amounts
to meet muscle requirements & maintain optimal
respiratory muscle force
• Vit A, C & E favorable impact on immune defenses.
COPD (CHRONIC
OBSTRUCTIVE
PULMONARY DISEASE)
Indeed, there is a viscous circle between impairment and malnutrition in
COPD: COPD

Difficulty Increased
consuming metabolic
food rate
worsening worsening

Chronic Increased
inadequate caloric
intake needs
Decreased Impaired
muscle strength aerobic
capacity

Malnutrition
( Kwiatkowski, et al. 1999)
Nutrition intervention (Tuberculosis)
• Screening for malnutrition all over age
• Nutrition assessment
• Nutrition counseling & support
• Micronutrients supplementation
• Side effects of OAT
•
Nutrition management
• No evidence support difference between other condition
• Support weight gain : BMR x 2
• Protein 15% or 1.2-1.5 gr/kgbb
Tuberculosis

• Many patients are developing drug-

resistant TB
Nutritional Factors that Increase Risk of
TB
• Protein-energy malnutrition: affects the immune system;
debate whether it is a cause or consequence of the
disease
• Micronutrient deficiencies that affect immune function
(vitamin D, A, C, iron, zinc)
Nutritional Consequences of TB
• Increased energy expenditure
• Loss of appetite and body weight
• Increase in protein catabolism leading to muscle
breakdown
• Malabsorption causing diarrhea, loss of fluids, electrolytes
MNT in respiratory failure
Causes of Acute Lung Injury (ALI)
• Aspiration of gastric contents or inhalation of toxic
substances
• High inspired oxygen
• Drugs
• Pneumonitis, pulmonary contusions, radiation
• Sepsis syndrome, multisystem trauma, shock,
,pancreatitis, pulmonary embolism
Acute Respiratory Distress Syndrome
(ARDS)
• Most severe form of acute lung injury
• Sepsis usually the underlying cause
• Increasing pulmonary capillary permeability
• Pulmonary edema
• Increased pulmonary vascular resistance
• Progressive hypoxemia
Goals of Treatment of ALI and ARDS
• Improve oxygen delivery and provide hemodynamic
support
• Reduce oxygen consumption
• Optimize gas exchange
• Individualize nutrition support
Nutrition Assessment in ALI and ARDS
• Indirect calorimetry best tool to determine energy needs in
critically ill patients
• In absence of calorimetry, use predictive equations with
stress factors
• Avoid overfeeding
• Patients may need high calorie density feedings to
achieve fluid balance
Nutrition Support in ARDS
• In one randomized, controlled trial in 146 patients with
ARDS, enteral nutrition with omega-3 fatty acids
(eicosapentaenoic acid) gamma-linonenic acid, and
antioxidants appeared to reduce days on mechanical
ventilation, new organ failure, and ICU length of stay
• This study was sponsored by Ross Laboratories, makers
of Oxepa
• Have been unable to locate further studies since then
Conclusion
• Malnutrition and respiratory disease have a strong
relationship
• High fat low CHO diet is given to hypercapnia patients