When Does Nutrition Impact Respiratory Function?

Abstract

Nutrition therapy is an essential aspect of patient care and an important determinant of outcomes in the ICU. Nutrition can impact respiratory function in a myriad of ways. Under- and overfeeding are two well-established ways by which nutrition impinges on respiratory function. Route of feeding, method of feeding, and carbohydrate composition of the diet are also other key factors regarding nutrition that influence outcomes in ICU patients. Recent studies are now elucidating the role of immune therapy in patients with acute respiratory distress syndrome. In the ICU, nutrition dogmas, such as the necessity of checking gastric residual volumes or utilizing full-calorie enteric feeds, as opposed to trophic feeds, are constantly being challenged by innovative clinical studies. Basic research brings the prospect of testing new approaches for ICU patients, such as the use of antioxidants to prevent diaphragm weakness in these patients. In this review article, we evaluate the recent observational and randomized control trials to critically appraise the evidence regarding nutrition in the ICU.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance, •• Of major importance

  1. 1.

    Liposky JM, Nelson LD. Ventilatory response to high caloric loads in critically ill patients. Crit Care Med. 1994;22:796–802.

    PubMed  Article  CAS  Google Scholar 

  2. 2.

    Covelli HD, Black JW, Olsen MS, Beekman JF. Respiratory failure precipitated by high carbohydrate loads. Ann Intern Med. 1981;95:579–81.

    PubMed  Article  CAS  Google Scholar 

  3. 3.

    Efthimiou J, Mounsey PJ, Benson DN, Madgwick R, Coles SJ, Benson MK. Effect of carbohydrate rich versus fat rich loads on gas exchange and walking performance in patients with chronic obstructive lung disease. Thorax. 1992;47:451–6.

    PubMed  Article  CAS  Google Scholar 

  4. 4.

    Kuo CD, Shiao GM, Lee JD. The effects of high-fat and high-carbohydrate diet loads on gas exchange and ventilation in COPD patients and normal subjects. Chest. 1993;104:189–96.

    PubMed  Article  CAS  Google Scholar 

  5. 5.

    Kane RE, Hobbs PJ, Black PG. Comparison of low, medium, and high carbohydrate formulas for nighttime enteral feedings in cystic fibrosis patients. JPEN J Parenter Enteral Nutr. 1990;14:47–52.

    PubMed  Article  CAS  Google Scholar 

  6. 6.

    al-Saady NM, Blackmore CM, Bennett ED. High fat, low carbohydrate, enteral feeding lowers PaCO2 and reduces the period of ventilation in artificially ventilated patients. Intensive Care Med. 1989;15:290–5.

    PubMed  Article  CAS  Google Scholar 

  7. 7.

    van den Berg B, Bogaard JM, Hop WC. High fat, low carbohydrate, enteral feeding in patients weaning from the ventilator. Intensive Care Med. 1994;20:470–5.

    PubMed  Article  Google Scholar 

  8. 8.

    Mehanna HM, Moledina J, Travis J. Refeeding syndrome: what it is, and how to prevent and treat it. BMJ. 2008;336:1495–8.

    PubMed  Article  Google Scholar 

  9. 9.

    Marik PE, Bedigian MK. Refeeding hypophosphatemia in critically ill patients in an intensive care unit. A prospective study. Arch Surg. 1996;131:1043–7.

    PubMed  Article  CAS  Google Scholar 

  10. 10.

    Gariballa S. Refeeding syndrome: a potentially fatal condition but remains underdiagnosed and undertreated. Nutrition. 2008;24:604–6.

    PubMed  Article  Google Scholar 

  11. 11.

    •• McClave SA, Martindale RG, Vanek VW, et al. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN J Parenter Enteral Nutr. 2009;33:277–316. These guidelines describe the existing evidence and expert opinion regarding delivery of eneral nutrition and TPN. The guidelines also address special considerations for nutrition in various patient populations.

    PubMed  Article  Google Scholar 

  12. 12.

    National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network, Wiedemann HP, Wheeler AP, et al. Comparison of two fluid-management strategies in acute lung injury. N Engl J Med. 2006;354:2564–75.

    PubMed  Article  CAS  Google Scholar 

  13. 13.

    • National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network, Rice TW, Wheeler AP, et al. Initial trophic vs full enteral feeding in patients with acute lung injury: the EDEN randomized trial. JAMA. 2012;307:795–803. The EDEN trial reviews two different feeding strategies for patients with ARDS. The study shows that trophic nutrition has some benefit, but care should be taken prior to applying this study's findings for all critically ill patients.

    PubMed  Article  Google Scholar 

  14. 14.

    Steevens EC, Lipscomb AF, Poole GV, Sacks GS. Comparison of continuous vs intermittent nasogastric enteral feeding in trauma patients: perceptions and practice. Nutr Clin Pract. 2002;17:118–22.

    PubMed  Article  Google Scholar 

  15. 15.

    Serpa LF, Kimura M, Faintuch J, Ceconello I. Effects of continuous versus bolus infusion of enteral nutrition in critical patients. Rev Hosp Clin Fac Med Sao Paulo. 2003;58:9–14.

    PubMed  Article  Google Scholar 

  16. 16.

    MacLeod JB, Lefton J, Houghton D, et al. Prospective randomized control trial of intermittent versus continuous gastric feeds for critically ill trauma patients. J Trauma. 2007;63:57–61.

    PubMed  Article  Google Scholar 

  17. 17.

    Metheny NA, Schallom L, Oliver DA, Clouse RE. Gastric residual volume and aspiration in critically ill patients receiving gastric feedings. Am J Crit Care. 2008;17:512,9. quiz 520.

    Google Scholar 

  18. 18.

    Montejo JC, Minambres E, Bordeje L, et al. Gastric residual volume during enteral nutrition in ICU patients: the REGANE study. Intensive Care Med. 2010;36:1386–93.

    PubMed  Article  CAS  Google Scholar 

  19. 19.

    Booker KJ, Niedringhaus L, Eden B, Arnold JS. Comparison of 2 methods of managing gastric residual volumes from feeding tubes. Am J Crit Care. 2000;9:318–24.

    PubMed  CAS  Google Scholar 

  20. 20.

    Juve-Udina ME, Valls-Miro C, Carreno-Granero A, et al. To return or to discard? Randomised trial on gastric residual volume management. Intensive Crit Care Nurs. 2009;25:258–67.

    PubMed  Article  Google Scholar 

  21. 21.

    •• Reignier J, Mercier E, Le Gouge A, et al. Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation and early enteral feeding: a randomized controlled trial. JAMA. 2013;309:249–56. This is a recently published study evaluating if clinicians need to check gastric residuals at all. The study found no difference in pneumonia, ICU days or mortality and patients who did not have gastric residual monitored received a higher percent of goal calories.

    PubMed  Article  CAS  Google Scholar 

  22. 22.

    Villet S, Chiolero RL, Bollmann MD, et al. Negative impact of hypocaloric feeding and energy balance on clinical outcome in ICU patients. Clin Nutr. 2005;24:502–9.

    PubMed  Article  Google Scholar 

  23. 23.

    Dvir D, Cohen J, Singer P. Computerized energy balance and complications in critically ill patients: an observational study. Clin Nutr. 2006;25:37–44.

    PubMed  Article  Google Scholar 

  24. 24.

    Rubinson L, Diette GB, Song X, Brower RG, Krishnan JA. Low caloric intake is associated with nosocomial bloodstream infections in patients in the medical intensive care unit. Crit Care Med. 2004;32:350–7.

    PubMed  Article  Google Scholar 

  25. 25.

    Krishnan JA, Parce PB, Martinez A, Diette GB, Brower RG. Caloric intake in medical ICU patients: consistency of care with guidelines and relationship to clinical outcomes. Chest. 2003;124:297–305.

    PubMed  Article  Google Scholar 

  26. 26.

    Taylor SJ, Fettes SB, Jewkes C, Nelson RJ. Prospective, randomized, controlled trial to determine the effect of early enhanced enteral nutrition on clinical outcome in mechanically ventilated patients suffering head injury. Crit Care Med. 1999;27:2525–31.

    PubMed  Article  CAS  Google Scholar 

  27. 27.

    Martin CM, Doig GS, Heyland DK, Morrison T, Sibbald WJ. Southwestern Ontario Critical Care Research Network. Multicentre, cluster-randomized clinical trial of algorithms for critical-care enteral and parenteral therapy (ACCEPT). CMAJ. 2004;170:197–204.

    PubMed  Google Scholar 

  28. 28.

    Stapleton RD, Jones N, Heyland DK. Feeding critically ill patients: what is the optimal amount of energy? Crit Care Med. 2007;35:S535–40.

    PubMed  Article  Google Scholar 

  29. 29.

    McClave SA, Lowen CC, Kleber MJ, et al. Are patients fed appropriately according to their caloric requirements? JPEN J Parenter Enteral Nutr. 1998;22:375–81.

    PubMed  Article  CAS  Google Scholar 

  30. 30.

    Dervan N, Dowsett J, Gleeson E, Carr S, Corish C. Evaluation of over- and underfeeding following the introduction of a protocol for weaning from parenteral to enteral nutrition in the intensive care unit. Nutr Clin Pract. 2012;27:781–7.

    PubMed  Article  Google Scholar 

  31. 31.

    Shanely RA, Zergeroglu MA, Lennon SL, et al. Mechanical ventilation-induced diaphragmatic atrophy is associated with oxidative injury and increased proteolytic activity. Am J Respir Crit Care Med. 2002;166:1369–74.

    PubMed  Article  Google Scholar 

  32. 32.

    Powers SK, Kavazis AN, Levine S. Prolonged mechanical ventilation alters diaphragmatic structure and function. Crit Care Med. 2009;37:S347–53.

    PubMed  Article  Google Scholar 

  33. 33.

    Levine S, Nguyen T, Taylor N, et al. Rapid disuse atrophy of diaphragm fibers in mechanically ventilated humans. N Engl J Med. 2008;358:1327–35.

    PubMed  Article  CAS  Google Scholar 

  34. 34.

    Prezant DJ, Valentine DE, Kim HH, Gentry EI. Effects of starvation and refeeding on adult male rat diaphragm contractility, fatigue, and fiber types. J Appl Physiol. 1993;74:742–9.

    PubMed  CAS  Google Scholar 

  35. 35.

    Lewis MI, Sieck GC, Fournier M, Belman MJ. Effect of nutritional deprivation on diaphragm contractility and muscle fiber size. J Appl Physiol. 1986;60:596–603.

    PubMed  CAS  Google Scholar 

  36. 36.

    Hart N, Tounian P, Clement A, et al. Nutritional status is an important predictor of diaphragm strength in young patients with cystic fibrosis. Am J Clin Nutr. 2004;80:1201–6.

    PubMed  CAS  Google Scholar 

  37. 37.

    Betters JL, Criswell DS, Shanely RA, et al. Trolox attenuates mechanical ventilation-induced diaphragmatic dysfunction and proteolysis. Am J Respir Crit Care Med. 2004;170:1179–84.

    PubMed  Article  Google Scholar 

  38. 38.

    Powers SK, Hudson MB, Nelson WB, et al. Mitochondria-targeted antioxidants protect against mechanical ventilation-induced diaphragm weakness. Crit Care Med. 2011;39:1749–59.

    PubMed  Article  CAS  Google Scholar 

  39. 39.

    Kawano T, Mori S, Cybulsky M, et al. Effect of granulocyte depletion in a ventilated surfactant-depleted lung. J Appl Physiol. 1987;62:27–33.

    PubMed  CAS  Google Scholar 

  40. 40.

    Fetterman Jr JW, Zdanowicz MM. Therapeutic potential of n-3 polyunsaturated fatty acids in disease. Am J Health Syst Pharm. 2009;66:1169–79.

    PubMed  Article  CAS  Google Scholar 

  41. 41.

    Gadek JE, DeMichele SJ, Karlstad MD, et al. Effect of enteral feeding with eicosapentaenoic acid, gamma-linolenic acid, and antioxidants in patients with acute respiratory distress syndrome. Enteral Nutrition in ARDS Study Group. Crit Care Med. 1999;27:1409–20.

    PubMed  Article  CAS  Google Scholar 

  42. 42.

    Pontes-Arruda A, Aragao AM, Albuquerque JD. Effects of enteral feeding with eicosapentaenoic acid, gamma-linolenic acid, and antioxidants in mechanically ventilated patients with severe sepsis and septic shock. Crit Care Med. 2006;34:2325–33.

    PubMed  Article  CAS  Google Scholar 

  43. 43.

    Singer P, Theilla M, Fisher H, Gibstein L, Grozovski E, Cohen J. Benefit of an enteral diet enriched with eicosapentaenoic acid and gamma-linolenic acid in ventilated patients with acute lung injury. Crit Care Med. 2006;34:1033–8.

    PubMed  Article  CAS  Google Scholar 

  44. 44.

    Stapleton RD, Martin TR, Weiss NS, et al. A phase II randomized placebo-controlled trial of omega-3 fatty acids for the treatment of acute lung injury. Crit Care Med. 2011;39:1655–62.

    PubMed  Article  CAS  Google Scholar 

  45. 45.

    Rice TW, Wheeler AP, Thompson BT, et al. Enteral omega-3 fatty acid, gamma-linolenic acid, and antioxidant supplementation in acute lung injury. JAMA. 2011;306:1574–81.

    PubMed  Article  CAS  Google Scholar 

  46. 46.

    Cook DJ, Heyland DK. Pharmaconutrition in acute lung injury. JAMA. 2011;306:1599–600.

    PubMed  Article  CAS  Google Scholar 

  47. 47.

    DeLegge MH. Aspiration pneumonia: incidence, mortality, and at-risk populations. JPEN J Parenter Enteral Nutr. 2002;26:S19–24. discussion S24-5.

    PubMed  Article  Google Scholar 

  48. 48.

    Komiya K, Ishii H, Umeki K, et al. Impact of aspiration pneumonia in patients with community-acquired pneumonia and healthcare-associated pneumonia: a multicenter retrospective cohort study. Respirology 2012.

  49. 49.

    • Fernandez JF, Levine SM, Restrepo MI. Technologic advances in endotracheal tubes for prevention of ventilator-associated pneumonia. Chest. 2012;42:231–8. This is a nice review of endotracheal tube advances to prevent ventilator associated pneumonia (VAP) and microaspiration. The review outlines and compares recent trials studying VAP incidence as well as some cost comparison information.

    Article  Google Scholar 

  50. 50.

    Zaloga GP. Aspiration-related illnesses: definitions and diagnosis. JPEN J Parenter Enteral Nutr. 2002;26:S2–7. discussion S7-8.

    PubMed  Article  Google Scholar 

  51. 51.

    Weiss CH, Moazed F, Dibardino D, Swaroop M, Wunderink RG. Bronchoalveolar lavage amylase is associated with risk factors for aspiration and predicts bacterial pneumonia*. Crit Care Med. 2013;41:765–73.

    PubMed  Article  CAS  Google Scholar 

  52. 52.

    Hsu CW, Sun SF, Lin SL, et al. Duodenal versus gastric feeding in medical intensive care unit patients: a prospective, randomized, clinical study. Crit Care Med. 2009;37:1866–72.

    PubMed  Article  Google Scholar 

  53. 53.

    • Davies AR, Morrison SS, Bailey MJ, et al. A multicenter, randomized controlled trial comparing early nasojejunal with nasogastric nutrition in critical illness. Crit Care Med. 2012;40:2342–8. This study compares nasogastric tubes to nasaljejunal tubes. This study did not find a significant difference between the two types of tubes. The discussion section of the study provides a nice review of several randomized trials comparing the two feeding tube types.

    PubMed  Article  Google Scholar 

  54. 54.

    Bartlett JG. How important are anaerobic bacteria in aspiration pneumonia: when should they be treated and what is optimal therapy. Infect Dis Clin North Am. 2013;27:149–55.

    PubMed  Article  Google Scholar 

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Conflict of Interest

Karen. S. Allen declares that he has no conflict of interest.

Ishan Mehta declares that he has no conflict of interest.

Rodrigo Cavallazzi declares that he has no conflict of interest.

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Correspondence to Rodrigo Cavallazzi.

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This article is part of the Topical Collection on Nutrition and Obesity

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Allen, K.S., Mehta, I. & Cavallazzi, R. When Does Nutrition Impact Respiratory Function?. Curr Gastroenterol Rep 15, 327 (2013). https://doi.org/10.1007/s11894-013-0327-3

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Keywords

  • Nutrition
  • Outcomes
  • Critical care
  • Lung function