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N utritional management of the patient with chronic obstructive pulmonary diseases

N utritional management of the patient with chronic obstructive pulmonary diseases. Prof. Entesar Sayed Ahmed Professor Of Chest Diseases Faculty Of Medicine For Girls Al- Azhar Universty 2014. Learning objective. Describe prevalence of malnutrition in COPD

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N utritional management of the patient with chronic obstructive pulmonary diseases

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  1. Nutritional management of the patient with chronic obstructive pulmonary diseases Prof. Entesar Sayed AhmedProfessor Of Chest Diseases Faculty Of Medicine For GirlsAl-AzharUniversty2014

  2. Learning objective • Describe prevalence of malnutrition in COPD • identify consequence of malnutrition in COPD • Describe mechanisms for weight loss in COPD • Recognize assessment of nutritional status • List nutrition therapy for chronic obstructive pulmonary disease

  3. Introduction • ChronicObstructivePulmonary Disease(COPD) is characterized by chronic air way limitation and a rang of pathological changes in the lung, some significant extrapulmonary effect, and important comorbidity which may contribute to severity of the diseases in individual patients.

  4. Recent evidence suggests that the disease also has several systemic effects, so interest in the nutritionalaspects of the disease has been resuscitated. • Several studies have shown that malnutrition is common in COPD and a relevant concern that may even affect prognosis.

  5. Malnourished COPD patients have greater gas trapping, lower diffusing capacity, and a lower exercise capacity when compared with heavier, non malnourished patients with a similar severity of disease. Malnutrition may be harmful in COPD patients.

  6. It is therefore important to be awareof this problem and respond quickly by providing nutritional support to the malnourished subjects with COPD. • Refeedingmalnourished COPD patients has been shown to improve both immune function and muscle function.

  7. It is not clear whether poor lung function is a cause of poor nutritional status or if poor nutritional status precipitates a decline in lung function results.

  8. Low body mass index (BMI) has been shown to be an independent marker of poor prognosis. •  Nutritional disorders have also been associated with higher morbidity, with involvement of both respiratory and peripheral skeletal muscle, lower exercise tolerance, increased dyspnea, and lower health-related quality of life.

  9. Prevalence of malnutrition in COPD • The exact prevalence of malnutrition in COPD is currently unknownbecause there is no diagnostic method that serves as a reference and no widely accepted definition. • Body weight provides a simple indication of nutritional status. • Repeated measurement of body weight can be used to monitor wasting, which is usually considered significant when it exceeds 5% to 10% per year.

  10. Previous studies have reported values for weight loss associated with COPD of 27%, 33%, and 47% • However, interpretation of the changes in body weight can be difficult due to water retention, which is often observed in patients with respiratory failure.

  11. Two methods have been used: • The first compares actual body weight with the ideal weight derived from standard tables. •  According to this method, malnutrition is subjectively considered to be present when the actual body weight is less than 90% ofthe ideal weight. • The second method uses BMI, that is, weight divided by height squared.

  12. Malnutrition is considered to be present when BMI is less than 20kg/m2 •  The prevalence of low body weight in 2 American series and a European series according to these definitions was similar--between 24% and 35%. • The prevalence of malnutrition among outpatients ranges from 22% to 24%, and it varies from 34% to 50% in patients hospitalized with COPD.

  13. Assessment of nutritional status • The assessment of nutritional status by body weight is simple but subject to substantial limitations in that it does not providequalitative information on body composition.

  14. Four different nutritional compartments can be identified: fat, skeletal, intracellular (also known as body cell mass), and extracellular. • The latter 3 form the lean body mass. • The body cell mass, which reflects metabolically active tissue (organs) and contractile tissue (muscle), is comprised of visceral protein and muscle protein.

  15. Approximately 60%of body cell mass is muscle. • This variable cannot be directly measured by any method in clinical practice, thus the variable that best reflects nutritional status is lean body mass.

  16. Loss of body cell mass is a common and serious problem for patients with end-stage chronic obstructive pulmonary disease (COPD), especially those with emphysema. • COPD patients with emphysema have lower body mass indexes and greater depletion of lean body mass than do COPD patients with chronic bronchitis .

  17. However, skeletal muscle weakness is associated with wasting of extremity fat-free mass (FFM) in COPD patients, independent of airflow obstruction and COPD subtype .

  18. Mechanism for weight loss in COPD • A variety of contributing factors have been proposed and it is likely that more than one factor is often at play. • Disturbancesin energy balance may reflect both the mechanical inefficiency of breathing and the reduced dietary energy intakes of these patients. • In COPD patients, Resting Energy Expenditure (REE) has been reported to be 15–20%above predicted values and the increased energy required for breathing has been suspected to account for the difference.

  19. Complex changes in metabolism are ultimately the result of inflammation, hypoxia, hypercapnia, nutritional deprivation, and pharmacologic therapy. • Stressors like nosocomial infection may exacerbate the situation by promoting hypermetabolism.

  20. Muscle proteolysis in the setting of systemic inflammatory responses appears likely in deteriorating patients. • The ubiquitin-proteasome pathway is activated in catabolic states to accelerate the breakdown of muscle proteins.

  21. Cytokine-mediated cachexia, similar to other end-stage organ failure syndromes, is possible in COPD patients. • Elevated concentrations of soluble tumor necrosis factor receptors and acute phase proteins have been observed and anorexia and decreased dietary intakes are common.

  22. Steroid therapy may further stimulate proteolysis and promote gluconeogenesis through inhibition of both protein synthesis and the transport of amino acids into muscle.

  23. Consequences of malnutrition • The impact of malnutrition on the respiratory system is that it decreases lung elasticity and pulmonary function, as well as reducing respiratory muscle mass, force and resistance. • Loss of body cell massis associated with a reduction in the mass of the diaphragm and of the respiratory muscles, resulting in declines in strength and endurance.

  24. Malnutrition also alters pulmonary immune mechanisms and breath control. • In malnourished patients, macronutrient and micronutrient deficiency generate a series of alterations that further increase the severity of COPD.

  25. Protein and irondeficiency can result in low hemoglobin levels, with subsequent decreased oxygen transport capacity. • Vitamin C deficiency affects collagen synthesis, which is important in the composition of the lung support connective tissue. • At the cellular level, muscle function can be compromised due to low levels of calcium, magnesium, phosphorus, and potassium

  26. The reduced availability of proteins and phospholipids also compromises the function of the surfactant, contributing to the alveolar collapse and consequently increasing respiratory effort.

  27. It is also worth mentioning that the mucus in the airways is composed of water, glycoproteins, and electrolytes, and that hypoproteinemia also leads to the development of pulmonary edema, due to the decreased colloidal osmotic pressure, which makes it possible for body fluids to move to the interstitium.

  28. The alterations in the immune system as a consequence of malnutrition leave the patient more susceptible to pulmonary infections. • Malnutrition results in the atrophy of the lymphoid tissue, principally affecting cell-mediated immunity.

  29. With renutritionand body weight gain, there is an improvement in the absolute lymphocyte counts and in the responsiveness to antigens in skin tests.

  30. The severe protein-calorie malnutrition also results in alterations in the complement system and increased serum levels of tumor necrosis factor, which can be accompanied by anorexia, muscle degradation, and altered metabolism of lipids by the inhibition of tissue lipoprotein lipase and by the pyrogenic effect.

  31. It has also been observed that malnutrition leads to the reductionof the tidal volume and of the number of sighs, provoking alveolar collapse and inadequate secretion removal, which, in turn, predispositions the patient to pulmonary infections.

  32. The respiratory pressures maximal inspiratory pressure and maximal expiratory pressure reflect the inspiratory and expiratory muscle force, respectively. • Weight loss in patients with COPD can result in low maximal inspiratory pressure values due to inspiratory muscle weakness

  33. The consequencesof the morphological, functional, muscular, and pulmonary alterations due to malnutrition in patients with COPD are as follows: • decreased respiratory performance upon exertion; acute respiratory insufficiency; difficulty in weaning from mechanical ventilation. • COPD significantly affects respiratory resistance and elasticity. • Reduced muscle resistance with subsequent predisposition to fatigue is the clearest functional effect of malnutrition on the diaphragm and the respiratory muscles .

  34. NUTRITION THERAPY IN COPD • The treatment for COPD includes a series of procedures, from prophylactic measures to those specifically related to the correction of the alterations caused by the disease. • A comprehensive treatment regimen can relieve the symptoms, reduce the number of hospitalizations, prevent premature death.

  35. Nutrition therapy is quite important in COPD due to its great impact on the morbidityand mortality caused by the disease. • The data in the literature show that malnutrition is associated with a high rate of mortality in COPD patients, from 33% at the onset of the weight loss process to as high as 51% after five years. • A formal rehabilitation program for patients with COPD, using a team approach, presents a highly efficacious result.

  36. Evaluation of the nutritional state in COPD • The objective of the evaluation of the nutritional state of patients with COPD is to identify the organic and metabolic alterations that depend on nutrition or that can be diminished by adequate dietary treatment.

  37. Various methods can be used in the evaluation of the nutritional state, Such methods include subjective global nutritional evaluation, evaluation of dietary intake, anthropometry, determination of body composition, and biochemical testing. • An isolated parameter does not characterize the general nutritional condition of an individual, and it is therefore necessary to use a combinationof various nutritional state indicators to increase the diagnostic precision.

  38. 1-Nutrition anamnesis • Is an evaluation method that makes it possible to predict or estimate the nutritional state of the patient through a qualitative and quantitative analysis of dietary consumption • The 24-hour recollection method and semi-quantitative survey of the frequency of food consumption can be used in the evaluation of the dietary consumption of the patient with COPD.

  39. The 24-hour recollection method provides detailed information on current consumption, as well as on the number and scheduling of the meals on the day prior to the day of the interview. • The semi-quantitative survey of the frequency of dietary consumption provides a list of different foods, as well as the frequency of consumption of each one of them.

  40. 2-Anthropometry • The anthropometric measures most often used are weight, height, skinfold thickness, and circumferences.

  41. 3-Bio-impedance • The bio-electrical impedance (bio-impedance) technique is employed to measure the conductive properties of an individual and thereby define the body composition and type, as well as to determine the volume and distribution of fluids and tissues. • The estimation of body composition through the use of bio-impedance has frequently been used, because it is easily applied and is a noninvasive method. • •Patients with emphysema ('pink puffers') typically present lower percentages of body fat and lower BMIs than do patients with chronic bronchitis ('blue bloaters') and normal individuals.

  42. 4-Biochemical testing • Is useful in the evaluation of the nutritional state of patients with COPD and contributes to the monitoring of the nutrition therapy as well.

  43. a-The creatinine/height index is used in the evaluation of the lean BMI in malnourished patients with COPD. • Creatinine is a metabolite derived from the nonenzymatic and irreversible hydrolysis of creatine and phosphocreatine • The size of the muscle protein pool of the patient is directly proportional to the quantity of creatinine excreted, and the expected 24-h excretion is related to the height of the patient. • Therefore, the creatinine/height index can be considered an extremely important muscle mass index in the evaluation of the nutritional state of patients with COPD who present muscle mass depletion.

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