14.2 Nutrition and Chronic Pulmonary Illnesses

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.

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.

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.

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.

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.

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)

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.

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.

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.

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.