NutritioninPulmonaryProblem-PPDSGiziKlinik (1)

5/25/2018 NutritioninPulmonaryProblem-PPDSGiziKlinik (1)

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Nutritionand

Pulmonary Problems

Bambang Heru Handojo


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Pulmonary Problems

Infection - Immunocompromised

Acute Respiratory Failure

Acute Respiratory Distress Syndrome Chronic Obstructive Pulmonary Disease

Pneumonia

Mechanical Ventilation Weaning From Mechanical Ventilation

Pulmonary Aspiration


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Starvation

respiratory epithelium: integrity

ciliary's function

pulmonary defense mechanism

Malnutrition in PulmonaryProblem


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Short-term starvation

surfactant:

secretion synthesis

Edelman NH, Rucker RB, Peavy HH. Nutrition and the

respiratory system. Rev Respir Dis. 1986:134:347352

Malnutrition in Pulmonary Problem


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Malnutrition in Pulmonary Problem

Malnutrition

System Immune Mechanism

Susceptible to Infection

Pulmonary Tuberculosis, Mycosis et al


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Malnutrition in Pulmonary

ProblemMalnutrition

respiratory muscle endurance

loss of strengthfatigue

alveolar ventilation hypercarbia

Hagaman M, Christian JW. Nutrition support in acute

respiratory failure. Cont Intern Med. 1994;6(7):2941.


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Malnutrition + Critical illness

expansion ECF

reduction ICF

anasarca

interstitial lungs water

Hagaman M, Christian JW. Nutrition support in acute

respiratory failure. Cont Intern Med. 1994;6(7):29

41.

Malnutrition in PulmonaryProblem


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Goals of Nutrition Therapy

Preventing malnutrition

Energy supply for breathing

Prevent or minimized loss of respiratorymuscle mass

Weaning from Mechanical Ventilation


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ACUTE RESPIRATORY FAILUREis the absence of the normal homeostatic state ofventilation as it relates to acid-base status of the

blood and the exchange of O2 and CO2

PaO2< 60 mm Hg, FiO2 > 0.5PaCO2> 50 mmHg, pH < 7.25

MECHANICAL VENTILATION

Acute Respiratory Failure


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Score of ALI:Chest Radiograph (1-4 quad>: 0-4

Hypoxemia Score : 0-4PEEP Score: 0-4Respiratory System Compliance: 0-4

No Lung Injury: 0Mild to Moderate Lung Injury: 0.1 2.5Severe Lung Injury (ARDS): > 2.5

Acute Lung Injury


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ARDS

Acute Respiratory DistressSyndrome Direct insult

aspiration of gastric content, inhalation of toxicsubstances, high inspired oxygen, drugs,pneumonitis, pulmonary contusion, radiation

Indirect insultsepsis syndrome, multisystem trauma, shock,pancreatitis, pulmonary embolism, disseminatedintravascular clotting, fat embolism, bypasssurgery


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EPA & DHA

Anti inflammatory effect

1. displacing AA from the cell membrane of alveolarmacrophage and neutrophils, thereby decreasing

its release by PLA22. competing with AA for metabolism by COX & LO

3. inhibiting release of AA from membrane

phospholipids and its further metabolism4. decreasing cytokine-mediated induction of

inflammatory gene expression ( eg. COX-2, TNF,IL-1, adhesion molecules)

Grimble, Proc Nutr Soc1998

Graber et all, J Lipid Mediat Cell Sig 1994


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Therapeutic Goals ARDS

1. Improve oxygen delivery & providehemodynamic support

2. Reduce oxygen consumption

3. Individualize nutritional support4. Optimize gas exchange


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CHO

Fat

Protein

O2

(L/g)

0,7

2

1

CO2prod

(L/g)

0,7

1,4

0,8

E pot

(Kkal/g)

4

9

4

O2Consumption & CO2

Production


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Recommendations for ARDS

Prevent over and under-feeding

Energy needs 25 30 kcal/kg BW

Protein needs 1.2

1.5 g /kg IBW Enteral nutrition if possible

Diet supplemented with EPA or EPA+GLA for 4-7 days

Provide certain micronutrients Prevent fluid overload


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INDICATION

Acute Respiratory Failure After major surgery

Therapeutic hyperventilation (intracranialhypertension)

Mechanical Ventilation


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The process of withdrawing frommechanical ventilatory support

True weaning is required in patient in whomthe respiratory muscles are weakened anddetrained

Complication: malnutrition, stress &immobility

Weaning From MechanicalVentilation


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Controlled Mechanical Ventilation (CMV)

Pressure Control

Assist/Control

Intermittent Mandatory Ventilation (IMV/SIMV)

Pressure Support (PS)

Continuous Positive Airway Pressure (CPAP)

MECHANICAL VENTILATION MODE


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20% of mechanically ventilated patients fail theirfirst attempt at weaning

> 40% of the time on mechanical ventilation spentfor weaning

The causes of prolonged ventilator dependencyare:

Hypoxemic respiratory failure

Respiratory muscle pump failure Psychological factors (frustration, uncertainty,

hopelessness, fear, and lack of mastery)

Apostolakos MJ. Weaning from mechanical ventilation.

In Critical Care The Requisites in Anesthesiology 2005:190-194

The Weaning from MechanicalVentilation


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Central Nervous System Unconciousness

Infection

Uncontroled Bronchodilator Insufficient

Physiotherapy

Nutrition Fluid Imbalanced

Blood & Electrolyte - disturbance

The Common Problems in Weaning


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Fluid overload

Acid-base changes

Electrolyte disturbances

Hypocalcemia, hypophosphatemia &hypomagnesemia



The Common Problems in Weaning- Relation to Nutrition Therapy


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Nutritional repletion:

muscle mass & fatigability of non-respiratory muscles

facilitate weaning



The Common Problems in Weaning- Relation to Nutrition Therapy


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The Risk of Nutrition

TherapyTube Feeding ASPIRATION

Refeeding Syndrome

Hypercapnia


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Tube Feeding

Risk factors of aspiration in tube feeding:

Malpositioned feeding tube

Improper feeding site

Large gastric volume

Supine position

Volume of Feeding


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Overfeeding

Overfeeding

High CO2 production+

respiratory function

respiratory failure

Hyperglycemia

Dyslipidemia

Hepatic steatosis

Hypophosphatemia

Hypokalemia

Hypomagnesemia

Fluid overload


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Chronic Obstructive Pulmonary Disease


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COPDCauses of COPD

airflow obstruction

hyperinflation and air trapping

flattening of the diaphragm

increased residual volume


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Nutrition depletion in COPD

AnorexiaHyper-metabolism (WOB )+

Inadequate calorie + protein intake

primary lung parenchymal diseaseimmunocompromise

respiratory muscle wasting

respiratory dysfunction

intubation & mechanical ventilation


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The recommended daily diet

for COPD should be:

- 28% calorie intake from carbohydrates

- 55% calorie intake from Fat - 12-20% calorie intake from protein

The 44th International Respiratory Congress Abstracts-On-Disk, November 7 - 10, 1998, Atlanta, Georgia.


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Clinical Nutrition 2 6


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Micronutrient Requirement

PhosphorusMagnesiumPotassium

Vitamin APyridoxineZnCo

SeVit E, vit C, beta carotene


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Gizi dan Rehabilitasi Paru

Insidens malnutrition yg tinggi padaPasien Rehabilitasi Paru, akan

meningkatkan suseptibilitas infeksidan mengakibatkan tingginyamortalitas dan morbiditas

P l P bl


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Pulmonary Problems Infection - Immunocompromised

Acute Respiratory Failure Acute Respiratory Distress Syndrome

Chronic Obstructive Pulmonary Disease

Pneumonia

Mechanical Ventilation

Weaning From Mechanical Ventilation Pulmonary Aspiration

Prolonged Nasogastric tube - cough

P l P bl s


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Pulmonary Problems Calori in Ventilated Patient Incr or Decr

PEG in Prolonged NGT

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NutritioninPulmonaryProblem-PPDSGiziKlinik (1)