NUTRITIONAL MANAGEMENT IN

RESPIRATORY DISEASES

A. Yasmin Syauki
Nutrition Departement
Faculty of Medicine, Hasanuddin University
syaukiyasmin@gmail.com
2018

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 PREFACE
• SKDI 2012, diseases related to nutrition (level 4A) :
– asthma bronchial
– acute bronchitis
– pneumonia, bronchopneumonia
– lung TB without complications

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 OBJECTIVES
• To explain the relationship between nutrition
and pulmonary function.
• To diagnose and to give nutritional
management in patient with (level
competence 4A) :
– Asthma bronchial
– Bronchitis acute
– Pneumonia, bronchopneumonia
– Lung TB without complications

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 CONTENTS
• Overview
• Relationship between nutrition and
pulmonary function
• Nutritional management in patient with :
– Asthma bronchial
– Bronchitis acute
– Pneumonia
– Lung TB without complications

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 OVERVIEW

• Respiratory system :
– Oxygenating tissues
– Removing waste
• Pulmonary surfactants :
– Highly active material composed of lipids and
proteins
– In the fluid lining the alveolar surface of the lungs
– Protects the lungs from injuries and infections

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 Figure 1. Structure of respiratory tractus
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 NUTRITION AND PULMONARY FUNCTION

• Food –quality and quantity nutrient- is important as

fuel to breathing activity
• Food and oxygen will produce Energy (E) and Carbon-
dioxide (CO2)
• This CO2 will be exhale by pulmonary function
• Functions of respiratory systems related to nutrition :
– exchanges gases (oxygen and carbon dioxide) between
blood and the atmosphere
– regulates blood acid-base (pH) balance

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 MALNUTRITION AND PULMONARY FUNCTION

• Malnutrition impairs :
– Respiratory muscle function,
• breakdown of respiratory muscles just as skeletal
muscle do in time of starvation or stress
– Ventilatory drive
– Response to hypoxia
– lung structure
• the supporting connective tissue in the lung system is
collagen, which required protein and vitamin C to build

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 MALNUTRITION AND PULMONARY FUNCTION

• Malnutrition impairs :
– Pulmonary defense mechanisms,
• malnutrition decreases the immune function lead to
susceptible infectious disease
– surfactant,
• malnutrition will decrease surfactant contributes to
collapse alveoli and working harder of breathing

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 Malnutritio
n

Poor lung
Anorexia growth
Decrease
Fatigue respiratory
muscle tone

Increase
effort to Chronic
breathing infection
Adverse Chronic
effects of inflammation
medications

Declining
pulmonary
status

Figure 2. Vicious cycle of malnutrition-pulmonary function

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 EFFECTS MALNUTRITION IN PATIENT WITH
PULMONARY DISEASES
• Respiratory muscle strength ↓ by 37%
• Maximum voluntary ventilation ↓ by 41%
• Vital capacity (lung volume)↓ 63%
• Diaphragmatic muscle mass ↓ to 60% of normal in
underweight patients who died of other ailments
• Decreased cough and inability to mobilize secretions
• Atelectasis and pneumonia
• Prolonged mechanical ventilation and difficulty
weaning with prolonged ICU stay
 EFFECTS MALNUTRITION IN PATIENT WITH
PULMONARY DISEASES
• Altered host immune response and cell-
mediated immunity
• Contributes to chronic or repeated pulmonary
infections
• Decreased surfactant production
• Decreased lung elasticity
• Decreased ability to repair injured lung tissue
 MACRONUTRIENTS AND RESPIRATORY
QUOTIENTS
• Respiratory quotients (RQ)
– RQ = CO2 eliminated/O2 consumed
– RQ from fat = 0,7
– RQ from protein= 0,8
– RQ from carbohydrates = 1,0
• Increases in CO2 (with subsequent increases in
RQ) may cause respiratory compromise in
patients with limited pulmonary reserve.

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 NUTRIENTS AND PULMONARY FUNCTIONS

• The evidence for the role of diet in pulmonary

disease is clear.
• Intake of fruit, fish, antioxidant vitamins, fatty acids,
sodium, or magnesium helps to alleviate symptoms
of asthma and chronic obstructive pulmonary
disease (COPD).
• Flavonoids, such as quercetin and resveratol, in
apples, onions, oranges, berries and red wine
support lung health.
• Vitamin D helps to maintain healthy lung function.
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 PULMONARY STATUS AND NUTRITIONAL
STATUS
• Decreases pulmonary function increases nutritional
requirement
– increases effort of pulmonary muscle to breathe
– increases incidence of chronic infections
• Decreases pulmonary functions decrease food and
nutrient intake
– shortness of breathe and decreased oxygen (O2)
saturation while eating decreases appetite
– anorexia associated with chronic disease

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 PULMONARY STATUS AND NUTRITIONAL
STATUS
• Decreases pulmonary functions decrease food and
nutrient intake
– GI distress and vomiting
– Pulmonary edema necessitates fluid restriction, limiting
calories from juices, milk and other beverages
– decreased pulmonary function causes general fatigue,
making food preparation difficult

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 THE GOAL OF NUTRITIONAL THERAPY
DURING PULMONARY DISEASES
• To prevent or minimize loss of respiratory
muscle mass
• To maximize pulmonary function
• To provide maintenance or repletion therapy

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ENERGY NEEDS IN NUTRITIONAL THERAPY
FOR PULMONARY DISEASES
• Goal : meet energy needs without overfeeding.
• Pulmonary patients typically have increased energy
needs.
• However, overfeeding increase strain on pulmonary
system and can lead to decreased function.
• General guidelines : 25-30 kcal/kgBW.
• If patient is experiencing a great deal of edema, use
patient’s usual “dry” weight.
• If patient is obese, adjust body weight to avoid
overfeeding

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 PROTEIN NEEDS IN NUTRITIONAL
THERAPY FOR PULMONARY DISEASES
• Goal : maintain or restore lung and muscle strength
and promote immune function.
• Pulmonary patients typically have increased protein
needs.
• General guidelines : 1.2-1.5 g/kgBW.
• Average healthy individual requires 0.8-1.0 g/kgBW

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 FAT AND CARBOHYDRATE NEEDS IN
NUTRITIONAL THERAPY FOR PULMONARY
DISEASES
• Recommended high fat, low carbohydrate diet when
trying to wean or during periods of acute respiratory
diseases.
• Recommended the following ratios :
– protein : 15-20% of total energy
– fat : 30-45% of total energy
– carbohydrate : 40-55% of total energy
• Excess carbohydrate increases CO2 production and
increase patient’s reliance on assistance.

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 DISEASES SPECIFIC ENTERAL FORMULATION

• There is limited evidence that pulmonary formulas

(high fat, low carbohydrate) have clinically benefits
compared to standard or nutrient-dense formulas
that provide adequate energy, regradless of
carbohydrate to fat ratio.
• Overfeeding calories has a greater impact on CO2
production than high carbohydrate feedings.
• Accurate calories better than low carbohydrate
formulas

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 DISEASES SPECIFIC ENTERAL FORMULATION

• High fat formulas are generally less tolerated than

standard formula.
• That formulas typically have high residual and feel
uncomfortable because fat decrease motility and
sticks around in the gut longer.
• Standard formulas are much less expensive and often
have better coverage by insurance companies.

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 LUNG ANATOMY
–NORMAL AND ABNORMAL-
 ASTHMA BRONCHIALE

• Bronchial asthma
involves paroxysmal
dyspnea
accompanied by
wheezing and is
caused by spasm of
the bronchial tubes
or swelling of their
mucous
membranes.
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 NUTRIENT AND BRONCHIAL ASTHMA

• Food sensitivities may be triggers for asthmatic episodes

(sulfites, shrimp, herbs) but not the most common causes.
• Provide healthy diet and maintain healthy weight.
• Be aware of drug nutrient interactions (steroids).
• Observational studies have reported associations between
asthma and dietary antioxidant (vitamin E, vitamin C,
carotenoids, selenium, polyphenols, and fruit),
polyunsaturated fatty acids (PUFAs), and vitamin D but not
supplemental forms.
• An enriched diet containing vitamin E, vitamin C, beta-
carotene, and phenolic substances may reduce disease-
related oxidative stress.
 NUTRIENT AND BRONCHIAL ASTHMA
Table 1. Nutrients and their potential mechanisms of effect
Nutrient Activity and potential mechanisms of effect

Carotenoids, vitamin C and Antioxidant for protection against endogenous and exogenous oxidant
vitamin E inflammation
Vitamin C Prostaglandin inhibition

Vitamin D Modulation of T-cell responses

Vitamin E Membrane stabilization, inhibition of immunoglobulin E production

Flavones and flavonoids Antioxidants, mast cell stabilizations

Magnesium Smooth muscle relaxation, mast cell stabilization

Selenium Antioxidant cofactor in glutathione peroxidase

Copper, zinc Antioxidant cofactors in superoxide dismutase. Zinc modulates T-cell responses

Omega-3 fatty acids Leukotriene substitution, stabilization of inflammatory cell membranes

Polyunsaturated fatty acids modulates T-cell response
Omega-6 fatty acids/trans-fatty Increased eicosanoid production, increased inflammation and worsening of
acids respiratory function
Sodium Increased smooth muscle contraction, reduced intake may increase airway
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 NUTRITIONAL MANAGEMENT IN BRONCHIAL
ASTHMA
• Infants should be exclusively breastfed to reduce the
risk of asthma in susceptible families.
• Provide balanced, small meals that are nutrient dense
(high quality protein, vitamins, and minerals) to reduce
infections.
• Use less sodium.
• Highlight foods rich in vitamin A and C, magnesium and
zinc. Use more brocolli, grapefruit, oranges, sweet
peppers, kiwi, tomato juice, and cauliflower for vitamin
C.
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 NUTRITIONAL MANAGEMENT IN BRONCHIAL
ASTHMA
• Quercetin in apples, pears, onions, oranges, and berries
should be encouraged (five or more servings per week).
• Omit specific food allergens for children if identified : as
milk, eggs, seafood, tree nuts, peanuts, fish, wheat, or
soy. For adults, tree nuts, peanuts, fish, and shellfish
allergies tend to persist.
• Salicylate sensitivity is common in 5% to 20% of
asthmaticus who are hypersensitive to aspirin. Many
fruits, some vegetables, spices, and nuts contain
salicylate.

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 NUTRITIONAL MANAGEMENT IN BRONCHIAL
ASTHMA
• Sulfites may aggravate asthma in 5% of this population,
especially adults with severe disease. Sulfite-containing
foods or beverage should be avoided.
• Omega-3 fatty acids from fish oils, walnuts, and flaxseed
are useful.
• Intake of fish may be beneficial to prevent asthma in
children. If fish is tolerated, consumption of fish two to
three times weekly may reduce leukotriene synthesis.
• If nuts are tolerated, include Selenium from Brazil nuts
and vitamin E from most other nuts.

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 BRONCHITIS ACUTE

• Bronchitis is
inflammation of the air
passage.
• Acute bronchitis is an
acute respiratory
infection that is
manifested by cough
and sputum
production that lasts
for no more than 3
weeks.

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 NUTRITIONAL MANAGEMENT IN BRONCHITIS
ACUTE
• Provide a regular or high-calorie diet, specific to the
patient’s needs.
• If milk gives a sensation of thickening mucus
secretions, skim milk may be better tolerated and is
important for adequate calcium consumption.
• A healthy diet should be recommended, with plenty
of fruits and vegetables.

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 NUTRITIONAL MANAGEMENT IN BRONCHITIS
ACUTE
• Provide adequate amounts of vitamin C and E,
selenium and potassium.
• Increase the intake of fluids (2-3 L), unless
contraindicated.
• Omega-3 fatty acid intake may be beneficial to
reduce inflammation.
• A low energy intake may be needed after the acute
phase to promote weight loss, improve BMI, and
promote a healthier level of respiratory functioning.

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 PNEUMONIA AND HIGH RISK FACTORS
• Pneumonia involves infection and acute inflammation of
the alveolar spaces of the lung.
• People at high risk for pneumonia include the elderly, the
very young, those with COPD, diabetes mellitus, heart
failure, sickle cell anemia, AIDS, or asthma and people
undergoing cancer therapy or organ transplantation.
• Dental plaque germs may lead to onset of pneumonia,
regular tooth brushing, flossing and dental check-ups are
recommended.
• The lung exposed directly to the athmosphere which
contains xenobiotics and pathogens, these are
continuously inhaled on a daily basis.
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 NUTRITIONAL MANAGEMENT IN PNEUMONIA

• Gluthatione (GSH) is the primary antioxidant that

lines alveolar space. The lung uses GSH to adapt to
its rapidly changing environment. Thus a diet rich in
antioxidants (selenium, vitamin E and vitamin C)
should be beneficial. However, antioxidant will not
prevent pneumonia.
• Enteral feeding is needed for patients who require
endotracheal tubes and mechanical ventilation.
• Sufficient fatty acid intake may be useful.

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 NUTRITIONAL MANAGEMENT IN PNEUMONIA
• If not contraindicated, offer 3 L or more of fluid daily
to liquefy secretions and to help lower elevated
temperature.
• Progress, as tolerated, to a high-calorie diet. If
overweight, allow normal calorie intake for age and
sex.
• Early enteral nutrition, properly administered, can
decrease upper GI intolerance and nosocomial
pneumonia.
• Frequent, small meals and soft diet may be
tolerated better (5-6 times daily).
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 NUTRITIONAL MANAGEMENT IN PNEUMONIA
• A multivitamin-mineral supplement may be beneficial,
especially including selenium, vitamin A, vitamin C,
vitamin D and vitamin E.
• Vitamin A is needed to keep mucous membranes healthy.
• Vitamin D regulates the production of the antimicrobial
peptides cathelicidin and beta-defensin-2, which play an
important role in the innate immune response to
infection.
• When possible, add more fiber to prevent constipation.
• Ensure adequate potassium intake, as from fruits and
juices.
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 NUTRITION RISK AND LUNG TB WITHOUT
COMPLICATIONS
• Lung TB is caused by a tubercle bacillus (M.
tuberculosis) invading the lungs and setting up an
inflammatory process.
• The risk of developing TB may be related to poor
nutritional status, low serum albumin level increases
the risk of TB.

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 NUTRITION RISK AND LUNG TB WITHOUT
COMPLICATIONS
• As early as birth, children are often deficient in vitamin
D, which modulates their immune function and
increases susceptibility to infections.
• Vitamin D signals within macrophages and enables
them to kill M. tuberculosis organism. This is an
intracrine-autocrine-paracrine system for vitamin D
that has been recognized.
• TB causes loss of appetite, constant fatigue, tissue
wasting, exhaustion, hemoptysis, cough lasting 3 weeks
or longer with occasional blood-tinged sputum, fever
or chills, profuse night sweats and weight loss.
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 EMERGING ISSUES IN LUNG TB WITHOUT
COMPLICATIONS
• TB has been declared as a global health emergency
by WHO because nearly one-third of the world’s
population is infected with M. tuberculosis.
• With a high prevalence of malnutrition, a relatively
low utilization rate of nutritional services, and the
potential effect of adverse reactions to therapeutic
drugs, careful attention is needed for this patient
population.

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 NUTRITIONAL MANAGEMENT IN LUNG TB
WITHOUT COMPLICATIONS
• The objectives :
– Maintain or prevent losses in weight. Reduce
fever. The basal metabolic rate is 20% to 30%
above normal to counteract fever of 102°F or
higher.
– Normalize serum calcium and vitamin D3 levels
and correct either hypo- or hypercalcemia.
– TB often coincides with nutritional deficiencies,
micronutrient supplementation may improve the
outcome of treatment.

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 NUTRITIONAL MANAGEMENT IN LUNG TB
WITHOUT COMPLICATIONS
• The objectives :
– Promote healing of the cavity
– Counteract neuritis from isoniazid (INH) therapy,
when used,
– Stimulate appetite, which is generally poor.
– Prevent dehydration
– Prevent lung inflammation, infections and
complications.

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 NUTRITIONAL MANAGEMENT IN LUNG TB
WITHOUT COMPLICATIONS
• Nutrition therapy :
– Use a well-balanced diet containing liberal amounts
of protein and adequate calories. It may be useful to
calculate energy needs as 35-45 kcal/kgBW if weight
loss has been significant and protein 1,5-2 g/kgBW.
– Use adequate fluids (35 mL/kg) unless otherwise
contraindicated.
– Ensure that the diet provide sufficient levels of
calcium. Foods high in vitamin D and vitamin E, zinc
and selenium should be highlighted.

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 NUTRITIONAL MANAGEMENT IN LUNG TB
WITHOUT COMPLICATIONS
• Nutrition therapy :
– Iron and vitamin C are needed for proper hemoglobin
formation and wound healing. Avoid excess iron
because it is a bacterial nutrient.
– B-complex vitamins, especially vitamin B6 are needed
to counteract INH therapy. Additional pyridoxine
supplementation of malnourished children is
advisable, particularly those HIV-infected.
– Use supplemental vitamin A in carotene form as it is
poorly converted.

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 Terima kasih

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