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Nutrition for Nurses

14.2 Nutrition and Chronic Pulmonary Illnesses

Nutrition for Nurses14.2 Nutrition and Chronic Pulmonary Illnesses

Learning Outcomes

By the end of this section, you should be able to:

  • 14.2.1 Discuss the impact of nutrition on pulmonary illness.
  • 14.2.2 Discuss the impact of nutrition on chronic pulmonary illness.

Nutrition Requirement for Optimal Pulmonary Health

Lung disease is the umbrella term for several diseases and disorders of the pulmonary system that prohibit the lungs from performing optimally (NIH, 2022b). Lung diseases inhibit and alter respiratory function, breathing capabilities, and lung capacity. Lung diseases vary in etiology. Infectious microorganisms cause some, while others maintain an environmental cause. Chronic pulmonary diseases cause long-term breathing problems, drastically impacting a client’s quality of life. These conditions include symptoms of cough, wheezing, and shortness of breath. Other common chronic pulmonary diseases include chronic obstructive pulmonary disease, asthma, pulmonary fibrosis, and pneumonia. Pulmonary conditions that are not long term include respiratory tract infections and pulmonary embolism.

Chronic Obstructive Pulmonary Disease (COPD)

Chronic or long-term lower pulmonary diseases are classified as chronic obstructive pulmonary disease (COPD). The COPD categories include emphysema and chronic bronchitis (Gozzi-Silva et al., 2021; NIH, 2022b; NIH, 2022d). These obstructive diseases are progressive and limit the volume of air that flows into and out of the airways, decreasing gas exchange and making it difficult to breathe (NIH, 2022d). See Figure 14.3. Emphysema results in damage between the walls of the air sacs, or alveoli, that exchange gas in the lungs (NIH, 2022d; Pahal et al., 2023). Without injury present, the alveoli easily expand and stretch with inhalation and deflate readily with exhalation (Pahal et al., 2023). Emphysema leads to permanent dilation of the airspaces and decreases alveolar and capillary surface area. For example, consider an overinflated balloon that does not maintain the same elasticity over time. The common cause of emphysema is exposure to cigarette smoking and other noxious gases, such as sulfur dioxide (Pahal et al., 2023). Chronic bronchitis is the result of continuous inflammation of the airway linings, causing increasing mucus with clinical manifestations that include a productive cough of at least 2 months occurring within a 2-year time frame (NIH, 2022b; Widysanto & Mathew, 2023). As with emphysema, cigarette smoking, active or passively, or inhaling toxic chemicals and industrial pollutants is the leading causative factor in developing chronic bronchitis.

A diagram of the stages of C O P D from healthy lungs, to environmentally diseased lungs, to lungs with C O P D. Healthy lungs have an open airway and alveoli that are light colored. The lungs are a uniform shade of pink. Environmentally diseased lungs have an airway that is narrower than normal and alveoli that are slightly darker. The lungs have a few darker colored patches on them. Lungs with C O P D have a severely restricted air way with barely any opening. The alveoli are quite dark and appear hardened. The lungs have many dark spots throughout. The disease begins with inhalation of air pollution and more systematic inflammation causes the closing of the airway. The first line of defense includes oxygen, supplementation, bronchodilators, antibiotics, corticosteroids, antivirals, mucolytics, proper nutrition, smoking cessation, and hydration. Potential complications of C O P D include bacterial virus, and fungal infections and increased smoking and air pollution will continue the damage. Signs and symptoms include anxiety, panic disorders, depression, dyspnea on exertion, and airway inflammation.
Figure 14.3 The COPD disease process begins as healthy lungs endure exposure to different noxious environmental exposures. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Chronic lung conditions such as COPD severely diminish the quality of life, so individuals should strive to consume foods that promote lung function throughout the chronic diseases states to prevent exacerbations (Collins et al., 2019; NIH, 2022b; NIH, 2022d; Pahal et al., 2023; Scoditti et al., 2019; Widysanto & Mathew, 2022). Exercise is limited in clients with COPD, because they often suffer from dyspnea on exertion as a condition symptom. The lack of exercise is attributed to muscle loss and dysfunction, resulting in fatigue. Even the act of eating might trigger dyspnea, leading to anorexia. If a client is faced with the choice between breathing and eating, they will breathe to survive, which why anorexia and malnutrition is a common finding in these clients. As anorexia is present, the risk for significant malnutrition increases while vital vitamin and nutritional depletion continues. The lack of critical nutritional components accelerates respiratory decline as respiratory muscles weaken and cough pressure diminishes. As cough pressure declines, mucosal buildup threatens potential complications such as pneumonia.

Unfolding Case Study

Part C

Read the following clinical scenario and then answer the questions that follow. This case study is a follow-up to Case Study Parts A and B.

Kai is in the clinic today for difficulty breathing upon walking. His current vital signs are listed on the left side of the following table. Kai states that he has smoked for 30 years and frequently eats fast food because his job demands long hours and he does not have time for grocery shopping. You notice a cough; Kai states he does not know when it began exactly. He has noted a decrease in his weight, and he has a hard time working the long days his job demands because he becomes short of breath. You look at his chart, shown on the right side of the following table, which includes his vital signs and exam notes from his visit last year.

Today’s Vital Signs Last Year’s Vital Signs and Exam Notes
Temperature: 97.6ºF
Blood pressure: 128/89 mm Hg
Heart rate: 99 beats/min
Respiratory rate: 28 breaths/min
Oxygen saturation: 89% on room air
(drops to 77% while walking)
Height: 6'0"
Weight: 268 lb
Temperature: 98.0ºF
Blood pressure: 126/82 mm Hg
Heart rate: 89 beats/min
Respiratory rate: 20 breaths/min
Oxygen saturation: 92% on room air
Height: 6'0"
Weight: 280 lb

The client presents with mild dry cough for 2 weeks. Client’s chest x-ray shows enlarged lung air pockets. The client does not have a history of respiratory conditions but stated he has smoked for 30 years. The client is a construction worker with a fluctuating dietary history. Recommendations for client include smoking cessation.
Table 14.2
5.
Based on the documented visit history, which of the following issues requires follow-up by the nurse during today’s visit?
  1. Smoking
  2. Hydration status
  3. Dietary recommendations
  4. Workplace safety
6.
The nurse is constructing a teaching plan for Kai to address potential complications of COPD. Which of the following conditions will the nurse include in the plan?
  1. Asthma
  2. Respiratory syncytial virus
  3. Pulmonary fibrosis
  4. Pneumonia

Asthma

Asthma is a chronic disease clinically characterized by recurrent inflammation and airway narrowing (Gozzi-Silva et al., 2021; Hashmi et al., 2023; NIH, 2022a). These symptoms of chronic inflammation result from irritation from correlated efforts between the respiratory epithelium and both the initial and the (later) adaptive immune responses. Hyperresponsiveness is the reaction of the airway results from the activation of the granulocytes, such as the eosinophils, lymphocytes, macrophages, and mast cells. The response of the granulocytes triggers the smooth muscle in the airways to contract and secret mucus and also includes microvascular leakages. As the airway swells, gas exchange is prevented, and symptoms such as shortness of breath, dyspnea, cough, and wheezing is present. The disease process is associated with childhood and can carry into adulthood, or it might occur in adulthood. The etiology of asthma relates to allergic and environmental factors such as hay fever, tobacco smoke, particulate matter, pollen, mold, dust mites, food, and eczema. Asthma has no cure, affecting 1 in 13 people in the United States (Centers for Disease Control and Prevention, 2022). Figure 14.4 provides a visual of a normal airway with asthmatic and asthma attack airways.

Diagram of a normal airway and an asthmatic airway. In a normal airway, the airway is wide open and the smooth muscle is relaxed. In an asthmatic airway, the muscle tightens and the airway is not as wide open. In an airway during an asthma attack, there is a bronchospasm, or tightened muscle, and mucus fills the already restricted space of the airway.
Figure 14.4 During an asthma attack, chronic inflammation triggers an immune response that causes the smooth muscles in the airways to tighten, preventing gas exchange and restricting the ability to breathe. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Pulmonary Fibrosis

Like scars that develop on the skin, pulmonary fibrosis involves scarring of the lung tissue (Krishna et al., 2022). Scar or fibrotic tissue does not function normally in gas exchange. The fibrotic tissue prevents oxygen flow from the alveoli into the bloodstream, leading to low oxygen levels and compromised lung capacity as the scar tissue stiffens. Pulmonary fibrosis etiology might be idiopathic or secondary to another illness, medication, radiation therapy, or environmental exposure (Agarwal & Huda, 2022; Krishna et al., 2022).

Nutritional intake significantly impacts clinical outcomes for individuals with pulmonary fibrosis. Nutrients are in high demand due to the increase in respiratory workload, activation of inflammatory mediators, hypoxemia, and lack of physical exercise (Faverio et al., 2020). As with COPD, malnutrition remains prevalent for those with inadequate nutrition intake. Some preferred treatment medications for pulmonary fibrosis cause diarrhea and other adverse effects such as food malabsorption. Specific dietary counseling by a registered dietitian is recommended for those who experience these effects.

Respiratory Tract Infections

Respiratory tract infections (RTIs) encompass a variety of microorganisms that cause respiratory symptoms in the individuals that contract them (LaRocque & Ryan, 2019; Saleri & Ryan, 2019). RTIs are commonly acquired viral infections. These infections manifest in either the lower tract as pneumonia or in the upper tract as bronchitis, rhinitis, sinusitis, otitis, pharyngitis, epiglottitis, and tracheitis. Systemic manifestations include fever, headache, sore throat, cough, chest pain, dyspnea, and myalgia (LaRocque & Ryan, 2019; Saleri & Ryan, 2019). Transmission occurs through direct droplet contact or inhalation (Saleri & Ryan, 2019). While many upper respiratory tract infections are short term, some may lead to pneumonia. Table 14.3 outlines several RTIs and their symptoms.

Respiratory Tract Infections Type Symptoms Recommendations
Upper respiratory tract
Common cold Sneezing, stuffy nose, runny nose, sore throat, watery eyes, fever, cough
  • Hot tea with lemon or hot soup for sore throat
  • Gargle with warm salt water
  • Cold liquids
  • Popsicles made with all-natural fruit and fresh fruit juices
  • Plenty of fluids (water)
  • Honey
  • Elderberry
  • Increasing vegetables
  • Reducing dairy intake until symptoms improve
  • Ginger
  • Chicken-noodle soup
Pharyngitis Sore throat, dry throat, pain with swallowing, pain with speaking
Acute rhinitis Sneezing, stuffy nose, runny nose, itchy nose, throat, eyes, clear drainage from ears
Acute otitis media Fever, ear pain, loss of balance, hearing difficulties
Laryngitis Hoarseness, raw and sore throat, dry cough
Tonsillitis High fever, headache, earache, feeling tired, voice changes
Lower respiratory tract
Acute bronchitis Runny nose, low-grade fever, congestion, wheezing, cough Same as for upper respiratory tract infections
Pneumonia Cough, difficulty breathing, rapid heartbeat, fever, loss of appetite
Table 14.3 Respiratory Tract Infections, Their Symptoms, and Dietary Recommendations to Alleviate Symptoms (sources: Green et al., 2020; Lucas et al., 2019; Saleri & Ryan, 2019; Thomas & Bomar, 2022)

Pneumonia

Pneumonia is a condition that leads to inflammation of lung parenchyma caused by infection, chronic pulmonary diseases, ventilator use, or aspiration (NIH, 2022c; Sattar & Sharma, 2022; Sanivarapu & Gibson, 2022). When germs migrate into the lungs, the immune system is activated, causing alveoli and lung parenchyma inflammation. The inflammation causes the lungs to fill with fluid or pus. When an infection is a cause, the types of pneumonia are classified by acquisition type: community (within 48 hours of hospital admission), hospital-acquired (nonintubated person after 48 hours of hospital admission), ventilation (within 48 hours after intubation), or health care–associated (hospitalization within last 3 months) pneumonia. Pneumonia can lead to further chronic complications for some clients, such as lung fibrosis, damaged lung parenchyma, necrotizing pneumonia, cavitation, empyema, abscess, and death (Sattar & Sharma, 2022; Sanivarapu & Gibson, 2022). When left untreated, the mortality rate for pneumonia is 30%.

Pulmonary Embolism

A pulmonary embolism is a cease in blood flow to the pulmonary artery or its branches. A pulmonary embolism Figure 14.5 causes decreased or no blood flow because a blood clot becomes dislodged and migrates to the lungs (Vyas & Goyal, 2022). As lipid plaques accumulate on the arterial walls, the body’s inflammation systems activate (Ashrobi et al., 2022). Initial lipid plaques evolve into fibrous plaques that activate the release of inflammatory markers and procoagulating factors. The process is known as atherosclerosis, and the activation of the platelets causes adhesion and aggregation that triggers clot formation. A thrombus is a clot formed in a blood vessel that prevents the natural flow of blood within the vessel through this process (Ashorobi et al., 2022; Vyas & Goyal, 2022). A thrombus that breaks off becomes an embolus. When it travels to the lungs and prevents the natural flow of blood within the lungs, it is known as a pulmonary embolism.

A diagram of the pulmonary arteries and veins in the lungs. A close up illustrates an embolism that is almost the entire width of the vein, blocking the flow of blood in the lungs.
Figure 14.5 A pulmonary embolism stops the flow of blood within the lungs. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Alternative Food and Supplement Options

A well-balanced diet is important for overall health and becomes especially important for the client who remains predisposed to pulmonary conditions. Specific dietary recommendations vary depending on the type and severity of the pulmonary disease. Certain foods have potential benefits for pulmonary disorders and should be included in the overall management and treatment of clients with pulmonary conditions.

Chronic Obstructive Pulmonary Disease (COPD)

While eating becomes a complex and breathless chore for clients with COPD, the nurse should educate clients on the proper nutritional intake to promote optimal pulmonary health and prevent COPD exacerbations. Clients who comprehend the need for appropriate healthy balance are met with improvements in health. A diet with high anti-inflammatory foods, such as fresh fruit and vegetables, with minimal consumption of processed sugar, salt, and fried fatty foods, is a solid recommendation from leading government entities. Macronutrient portion intake includes 15–20% proteins, 30–35% fats, and 40–45% carbohydrates (Collins et al., 2019; Hancu, 2019; Scoditti et al., 2019). Protein-required measurements equate to 1.2–1.5g protein/kg (Collins et al., 2019; Hancu, 2019).

Micronutrients from oral nutritional supplements that maintain antioxidant and anti-inflammatory qualities include vitamins A, C, and E. These vitamins, within their function, protect and prevent the progression of COPD. Vitamin D has been found to reduce COPD exacerbation rates (Collins et al., 2019). Individuals with COPD should include vitamin C at 75 mg/day for females and 90 mg/day for males—vitamin D at 600 IU for adults and 800 IU for people aged 70 or older (Hancu, 2019).

As nurses perform their assessments, the should use the information the gather in the client’s nutritional planning and as client teaching opportunities. While completing the assessment of a client with COPD, the nurse should consider:

  • Some clients with COPD may appear overweight because of their free-fat mass index or visceral fat-area measurements (Hancu, 2019).
  • Malnutrition is still of concern in these clients (Hancu, 2019).
  • Avoid any judgment toward clients who are overweight.

In addition, the nurse should teach the client to:

  • Prepare and/or consume nutritionally dense meals.
  • Eat small, frequent meals.
  • Rest before mealtimes.
  • Time meals when energy level is at its highest.
  • Aim for a BMI between 20–24, maintain muscle mass, and include pulmonary rehabilitation.
  • Choose food options that require minimal energy expenditure in preparation.
  • Limit alcohol consumption.

Asthma

While some food triggers asthma and allergic symptoms, several foods and food groups have been shown to reduce the risk for developing asthma (Alwarith et al., 2020). Recommendations include daily ingestion of one or more servings of fruits and vegetables and whole grains, which may reduce the risk in children, adolescents, and adults. These food groups have also been shown to make asthma symptoms more manageable and are inversely related to wheezing in children because of the antioxidant effects and preventative oxidative damage. Fruit intake decreases asthma symptoms and the sensitization by inhaled allergens. The anti-inflammatory results of flavonoids in raw vegetables (lost during the cooking process) are believed to explain the association between raw vegetable consumption and well-managed asthma (Alwarith et al., 2020). High-fat intake, commonly in Western dietary preferences, is associated with worsening airway inflammation and lung function limitations. Clients with asthma should consider a plant-based diet, vegetarian diet, or strictly vegan foods to reduce asthma risk and decreases the need for as-needed asthma medication use. If the client decides on a plant-based diet, counseling by a registered dietitian should be included to avoid nutritional deficiencies.

According to Alwarith et al. (2020), a positive relationship exists between dairy consumption and concurrent asthma symptomology. Current dietary guidelines recommend 3 servings per day of dairy for clients with asthma, because it supplies calcium and vitamin D. Consultation with an allergist is recommended if dairy intake must be avoided (Comerford et al., 2021). The nurse should teach the clients who wish to avoid dairy products to seek plant-based milks that are fortified with vitamin D. See Table 14.4 for the various supplements and their relationship to lung anatomy and physiology.

Supplement Relationship with Pulmonary System Food Sources
Vitamin E
  • Stops oxidative damage and lung inflammation Sunflower, safflower, and soybean oil
  • Almonds
  • Peanuts
  • Pumpkin
  • Red bell pepper
Vitamin C
  • Encourages airway hydration and decreases free radicals
  • Controls immune-system cytokines
  • Stops oxidative damage
  • Makes asthma symptoms more manageable
  • Citrus (oranges, lemon, and grapefruit)
  • Bell pepper
  • Strawberries
  • Tomatoes
  • Cruciferous vegetables (broccoli, Brussels sprouts, cabbage)
Selenium
  • Protects against oxidative damage and lung inflammation
  • Pork
  • Beef
  • Turkey
  • Fish
  • Eggs
  • Beans and nuts (Brazil nuts)
Vitamin D
  • Aids the immune system and response
  • Cod liver oil
  • Salmon
  • Fortified foods such as (dairy and plant milks, orange juice)
  • Eggs
Magnesium
  • Relaxes smooth muscle, used in asthma exacerbation; need monitoring to prevent hypermagnesemia
  • Pumpkin seeds
  • Chia seeds
  • Almonds
  • Boiled spinach
  • Cashews
  • Peanuts
  • Soy milk
  • Rolled oats
Table 14.4 Function of Micronutrients Within the Pulmonary System and Food Examples (sources: Allen & Sharma, 2023; Alwarith et al., 2020)

Pulmonary Fibrosis

The adoption and continued consumption of unhealthy dietary selections increase and accelerate the risk for chronic diseases. Diets high in saturated fats increase the risk for pulmonary fibrosis development in both idiopathic and age-related cases (Mercader-Barcelo et al., 2020). In the same analysis, Mercader-Barcelo et al. (2020) state that a diet high in unsaturated fats reduces the severity of pulmonary fibrosis and the development of pulmonary fibrosis. A diet high in saturated fats and high fructose corn syrup (sodas, candy, processed foods) sped up the development of pulmonary fibrosis, while a diet including plant-derived polysaccharides has shown antifibrotic effects. Plant-based polysaccharides include coconut fiber, barley, oats, wheat bran, and chicory root. The amino acids arginine, glycine, and L-norvaline have demonstrated protection against pulmonary fibrosis in animal studies as they reduce the buildup of neutrophils and macrophages in peripheral blood. As with the chronic illnesses COPD and asthma, including foods high in vitamins A, B, C, D, and E is recommended.

Respiratory Tract Infections and Pneumonia

A healthy, balanced food intake boosts the immune system and helps prevent respiratory tract infections. Meeting optimal pulmonary health nutritional requirements moderates the body’s immune response, promoting lung health and respiratory homeostasis (Gozzi-Silva et al., 2021; Scoditti et al., 2019). Nutritional requirements for respiratory tract infections (RTI) and pneumonia are similar. Undernutrition is associated with an increased risk for frailty, difficulty in healing, increased risk for infection and worsening condition, morbidity, and mortality. A decrease in nutritional status predicts life expectancy in clients who begin with an RTI and develop pneumonia; becoming winded from eating leads to further deterioration of the condition. Nurses should seek to promote healthy habits to prevent and treat RTI with attention to vaccinations, adequate hydration, hand hygiene, smoking cessation, exercise, and nutrition.

Vahid and Rahmani (2021) recommend an anti-inflammatory diet to prevent and manage RTI and pneumonia associated with infections and COPD. Their definition of an anti-inflammatory diet includes using turmeric, ginger, garlic, onion, saffron, vitamin C, vitamin D, zinc, and omega-3 fatty acids. They conclude that these supplements, bulbs, and spices decrease symptoms, minimize the duration, and prevent future infections. Consumption of the micronutrients vitamin C, vitamin D, and zinc play a role in strengthening and protecting the immune system. Adequate protein intake also supports the immune system per Vahid and Rahmani (2021). They state that the anti-inflammatory diet not only aids the immune system but also boosts lung function and decreases oxidation.

Turmeric is a spice hailed for its anti-inflammatory properties. Turmeric contains curcumin (Vahid & Rahmani, 2021), which inhibits the expression of cytokines, thus decreasing the inflammatory response. This inhibitor has also been proposed as an antiviral intermediary for RTI (Vahid & Rahmani, 2021).

Ginger also belongs to the curcumin category, demonstrating similar antiviral and anti-inflammatory responses, such as its classmate turmeric. Ginger is thought to act by diminishing lung inflammation. See Figure 14.6.

Cooked wild rice with bite-sized pieces of ginger, carrots, peas, and celery on a plate.
Figure 14.6 Ginger, which has been shown to have anti-inflammatory effects, can be added to dishes as an ingredient or a spice. (credit: “English: Wild rice, ginger, carrots, peas, and celery - Massachusetts, USA” by Daderot/Wikimedia Commons, Public Domain)

Garlic has antioxidant, anti-inflammatory, and cholesterol-lowering effects. Garlic is high in folic acid, vitamin C, calcium, iron, magnesium, potassium, zinc, vitamin B2, vitamin B1, and vitamin B3. Garlic is thought to have antiviral, antibiotic, and antifungal effects on the body. See Table 14.5.

Source Role in the Body
Garlic
  • Aids the immune system by preventing biosynthesis of inflammatory markers
  • Related to the deterrence of virus from attaching to its host cells
Onions
  • Anti-inflammatory properties because of organosulfur compounds with quercetin and allicin
  • Prohibit virus from attaching to its host cells
  • Improves lung function as antioxidant, anti-inflammatory, and antiviral
Vitamin C
  • Neutralizes free radicals
  • Minimizes anti-inflammatory markers
  • Inactivates and interferes with virus proliferation
Vitamin D
  • Strengthens the immune system and helps to prevent RTI
  • Anti-inflammatory properties by limiting inflammatory cytokine response
Zinc
  • Potentiates antioxidant and anti-inflammatory properties
  • Strengthens the immune system by controlling inflammatory cytokines
Omega-3 fatty acids
  • Play a role in lung tissue remodeling
Table 14.5 Micronutrients and Their Role in Pulmonary Health (source: Vahid & Rahmani, 2021)

Pulmonary Embolism

The American diet contains detrimental inflammation-causing triggers. Yuan et al. (2021) observed that a higher intake of French fries increased the risk for thrombosis. The incidence of pulmonary embolism decreased with a diet high in fresh fruits and vegetables. Pneumonia and pulmonary embolism have inflammatory response activation as compensatory mechanisms to combat the triggers of the disease processes.

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