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Chronic Obstructive Pulmonary Disease (COPD) A process characterized by the presence of chronic bronchitis, emphysema, or both, leading to the development of airway obstruction What is COPD? What is COPD? COPD is a serious lung disease that makes it hard to breathe. airways are partly blocked, which makes it hard to get air in and out Emphysema- damage to air sacs in lungs Chronic bronchitis- swelling of air passages that lead to lungs Statistics 3rd leading cause of death in the U.S. Over 12 million are currently diagnosed and an estimated additional 12 million have it but haven’t been diagnosed 6 7 8 Etiology I am doing it, my etiology COPD Causes Smoking (90%) Environmental factors Air pollution, confined kitchen areas Genetics: α1-antitrypsin Produced in liver Protects lung against elastase Elastase breaks down elastin No elastin= no recoil Deficiency liver and lung failure Less than 1% of COPD patients Without smoking Emphysema Imbalance of antiproteases & proteases Normal Cigarette smoke oxidation α1-antitrypsin deficiency Cigarette smoke recruit neutrophils Increased proteases Emphysema α1-antitrypsin deficiency & increased proteases Collagen and elastin destruction Flabby lung ↓ recoil Abnormal enlargement & destruction of alveoli ↓ SA Chronic Bronchitis Cigarette smoke irritants inflammation of airway Hyperplasia and hypertrophy of mucus glands Hypertrophy of goblet cells increased mucus Smaller airway + more mucus = mucus plug 14 Case Study SB Age 62 Smoking history: 1 pack/day for 46 years Quit 1 year ago Pathophysiology Physiology of Pulmonary System Functions Acid-Base Balance Synthesize arachidonic acid ACE converts Ang. I to Ang. II Gas exchange Prostaglandins, Leukotrienes Surfactant Immune defense Gas Exchange Basic Pathophysiology Emphysema Permanent enlargement of acini with alveolar destruction Closure of small airways Primary: Alpha-1 Antitrypsin deficiency (inherited) Secondary: Inability to inhibit proteolytic enzymes (smoking, etc.) Chronic Bronchitis Hypersecretion of thick immobile mucus and productive cough Mucus obstruction of bronchioles Continuous bronchial inflammation * Common for patients to display both types Inflammation of COPD Emphysema Pathophysiology Smoke irritants cause inflammation of the epithelial Protease activity increased by cytokines Elastase, Cathepsin, Metalloprotease. Imbalance of proteases and anti-proteases cause a breakdown on elastin in alveolar septa Reduced elastic recoil and expiration Eliminated portions of pulmonary capillary bed Diminished airway caliber Air-trapping (causing barrel chest) Bronchoconstriction (caused by persistent inflammation) Emphysema Chronic Bronchitis Pathophysiology Smoking/irritants stimulate mucus production Ciliary function impaired= reduced mucus clearance Bacterial growth and inflammation= more mucus production Bronchial/Bronchiolar walls thicken Persistence involves bronchospasms and narrowing of the airways Obstuction (Mucus + wall thickening + lumen narrowing) Airway collapse in expiration Chronic Bronchitis 25 Effects on Energy Affect on energy metabolism Protein degradation - Cachexia Acute Exacerbations Accelerated loss of lung function and poor quality of life Severe Pulmonary Hypertension PA:A ratio >1 =pulmonary artery enlargement Other effects: Increase in dyspnea, hypercapnia, cough, and/or sputum production New strains of bacteria or viruses; environmental factors Ischemia, Heart Failure, Thromboembolism Cor Pulmonale Late stages From chronic PAH: Low PAO2 /Hypoxia causes pulmonary vasoconstriction Can be reversed if PACO2 is cleared but… Resistance to PA blood flow Increased workload of RV Peripheral edema noted Signs & Symptoms Emphysema No mucus or cough Barrel chest ↓ lung plasticity & hyperinflation Pressure around the lung greater than pressure in the lung Lung collapse Trapped air Expand anteroposteriorly Emphysema Breathing Habits Lean forward Stabilizes chest Allows max expansion Accessory muscles Pursed lips More air out before lung collapse Emphysema Older (>50) Underweight, cachectic Late cor pulmonale Decreased DLCO ↓ alveolar SA “Pink puffers” Chronic Bronchitis Hypersecretion of mucus and chronic productive cough for 3 months for 2 consecutive years Shorteness of breath, even at rest Wheezing Normal weight but often overweight Chronic Bronchitis V/Q Mismatch V= Ventilation; air that reaches alveoli Q=Perfusion; blood that reaches alveoli Hypoxemia Cyanosis around lips “Blue bloaters” Stimulates renal secretion of erythropoietin High hematocrit Vasoconstriction hypertension early cor pulmonale Case Study “I am gasping for air” “I am coughing up a lot of phlegm” “I am always short of breath” No cyanosis or clubbing Wheezing Uses accessory muscles at rest Diagnosis Spirometry Pt inhales & then exhales as much and as fast as possible Measures FVC FEV1 FEV1/FVC Spirometry Spirometry Post-bronchodilator FEV1 / FVC <.7 confirms airflow limitation that is not fully reversible Diffusion of Lung Capacity DLCO Patient inhales small amount of CO Compare the amount exhaled by amount inhaled Determines amount absorbed ↓ indicative of emphysema but not chronic bronchitis Prognosis Prognosis Not curable Slow damage Prevent exacerbation acute change in symptoms to needing a change in therapy dyspnoea cough and/or sputum 43 Quality of Life ADLs http://www.youtube.com/watch?v=G3vmSDXH wMI Case Study “I’m hardly able to do anything for myself…my husband had to help me out of the shower this morning.” Treatment Treatment No cure Quite smoking Walk to strengthen muscles needed for breathing Avoid cold air Avoid smoke, make sure no one smokes in your home Reduce air pollution by getting rid of fireplace smoke and other irritants 48 Medications: Bronchodilators Inhalers (Bronchodilators) work to relax the muscles around the airways, to help open them and make it easier to breathe. Some Inhalers include: ipratropium (Atrovent), tiotropium (Spiriva), salmeterol (Serevent), formoterol (Foradil), or albuterol Medications: Inhaled Steroids Reduce lung inflammation Most commonly used inhaled corticosteroids: fluticasone propionate, budesonide, and beclometasone dipropionate Pulmonary Rehab Multidisciplinary program including Medical management Exercise Breathing retraining Education Emotional support Nutrition counseling Oxygen Therapy Ways to test need: Arterial Blood Gas Test Oxometer Oxygen Delivery Oxygen Concentrators Compressed Oxygen Cylinders Liquid Oxygen Cylinders Oxygen Concentrator Compressed Oxygen Cylinder Liquid Oxygen Cylinder Surgery Only a few patients benefit from surgical treatment Surgery to remove parts of the diseased lung can help the less diseased areas work better Lung transplant for severe cases Case Study-Treatment Oxygen therapy Endotracheal intubation Enteral feeding due to high residuals Alternative Medicine Extracts from ivy or thyme are popular in many European countries Clinical Trial: Ivy leaf extract vs. Ambroxol tablets (conventional treatment). Vital Capacity: Weighted Mean Difference 0.24 (-0.22–0.7) Alternative Medicine Honey Thyme Oil Xiao Chuan (XCP) Nutritional Assessment Physical Observations Barrel Chest Physical Observations • Finger clubbing • Cyanosis Client History Medications (e.g, steroids): Nutritional supplements (e.g., herbals): Previous Oxygen use Adherence with previous nutrition prescription: Successes and barriers Anthropometrics Weight Status Body Composition Emphysema Chronic Bronchitis Energy Needs Energy Needs in Stable COPD Stress factor to account for inflammation Prevent obesity (chronic bronchitis) Increased work of breathing Chronic infection Chest physical therapy Pulmonary rehabilitation exercise programs Altered metabolism (anabolism, catabolism) Anthropometrics • Weight Status • Cor Pulmonale • Body Composition • Emphysema • Chronic Bronchitis • Energy Needs • Bone density screening • 18% of men and 30% of women had osteoporosis • 42% of men and 41% of women had osteopenia Food History Preferences Usual meal pattern Dietary restrictions Food allergies and intolerances/Food aversions Supplement intake Appetite ADLs Symptoms interfering with ability to consume adequate intake: Shortness of breath Fatigue Ability to secure and prepare food Taste and smell changes Chewing or swallowing difficulties Pain when eating Nausea and vomiting 69 Case Study • Poor appetite • Coughing makes it hard to eat • Food doesn’t taste good • PES statement: Inadequate oral intake related to side effects to acute exacerbation of COPD as evidenced by weight loss and anorexia. MNT MNT Goals Facilitate nutritional well-being Lean body mass to adipose tissue ratio Correct fluid imbalances Prevent Osteoporosis Manage drug-nutrient interactions Facilitate nutritional well-being Possible Problems Solutions Fatigue Eat high calorie foods when hungry Coughing during meals Eat slowly Aspiration Feeling bloated or full Include more fiber Dry mouth Drink adequate fluids with meal Inability to prepare own foods Select easy to prepare meals or seek assistance Lean body mass to adipose ratio Energy Needs Prevent excess weight gain in early stages Calorie control if weight loss is needed Harris-Benedict equation Women • 655 + (9.6 * kg) + (1.8 * cm) - (4.7 * age) Men • 66 + (13.7 * kg) + (5 * cm) - (6.8 * age) Stress factor = 1.2-1.3 Exercise factor if needed Lean body mass to adipose ratio Macronutrients Protein 1.2-1.7 g/kg Proportions to balance respiratory quotient 15-20% from protein 30-45% from fat 40-55% from carbohydrates Oral nutritional support “There is limited evidence to support consumption of a particular macronutrient composition of medical food supplementation.” -NCM 77 Lean body mass to adipose ratio Vitamin and minerals Vitamin C Vitamin D and K supplementation Calcium Restrictions in fluid-electrolyte imbalances Na+ restrictions K+ restrictions Correct fluid imbalances Normal 30-35 ml/kg Cor pulmonale Fluid restrictions Na+ restrictions Prevent Osteoporosis Why? Decreased physical activity Inhaled steroids? Scan for osteoporosis/osteopenia Ensure adequate calcium consumption Drug-nutrient Interactions Ipratropium (Atrovent) Anticholinergic drugs Decreased secretions Dry mouth Contains Soy lecithin Albuterol Theophylline Ø Bronchodilators that suppress the appetite COPD: Ain’t nobody got time for that.