Acute effects of different nutritional supplements on symptoms and functional capacity in patients with chronic obstructive pulmonary disease

Eating and drinking experience in patients with idiopathic pulmonary fibrosis: a qualitative study

OBJECTIVE

To explore eating and drinking experiences of patients with idiopathic pulmonary fibrosis (IPF), the impact of any changes associated with their diagnosis and any coping mechanisms developed by patients.

SETTING

Pulmonary fibrosis support groups around the UK and the regional Interstitial Lung Diseases Clinic, Newcastle upon Tyne.

PARTICIPANTS

15 patients with IPF (9 men, 6 women), median age 71 years, range (54-92) years, were interviewed. Inclusion criteria included competent adults (over the age of 18 years) with a secure diagnosis of IPF as defined by international consensus guidelines. Patients were required to have sufficient English language competence to consent and participate in an interview. Exclusion criteria were a history of other lung diseases, a history of pre-existing swallowing problem of other causes that may be associated with dysphagia and individuals with significant communication or other memory difficulties that render them unable to participate in an interview.

DESIGN

A qualitative study based on semistructured interviews used purpose sampling conducted between February 2021 and November 2021. Interviews were conducted via video videoconferencing call platform or telephone call, transcribed and data coded and analysed using a reflexive thematic analysis.

RESULTS

Three main themes were identified, along with several subthemes, which were: (1) Eating, as such, is no longer a pleasure. This theme mainly focused on the physical and sensory changes associated with eating and drinking and their effects and the subsequent emotional and social impact of these changes; (2) It is something that happens naturally and just try and get on with it. This theme centred on the self-determined strategies employed to manage changes to eating and drinking; and (3) What is normal. This theme focused on patients seeking information to better understand the changes in their eating and drinking and the patients' beliefs about what has changed their eating and drinking.

CONCLUSIONS

To our knowledge, this is the first study to report on IPF patients' lived experience of eating and drinking changes associated with their diagnosis. Findings demonstrate that some patients have substantial struggles and challenges with eating and drinking, affecting them physically, emotionally and socially. There is a need to provide better patient information for this area and further study.

Markers of respiratory function response to high-carbohydrate and high-fat intake in patients with lung diseases: a systematic review with meta-analysis of randomized clinical trials

BACKGROUND

Macronutrients can differently affect respiratory function markers such as VO₂ , VCO₂ , PaO₂ , PaCO₂ and respiratory quotients (RQ), but systematic appraisal of the evidence on randomized clinical trials (RCTs) is lacking.

OBJECTIVE

To compare the response of respiratory function markers to high-carbohydrate and high-fat intake in patients with lung diseases.

METHODS

Systematic review conducted according to Cochrane Collaboration recommendations, reported following PRISMA 2020. PubMed, EMBASE, Scopus, and Cochrane CENTRAL were searched up to July/2021. Two reviewers selected the RCTs and extracted the data. Risk of bias and the certainty of evidence were assessed by RoB 2 and GRADE, respectively. Statistical and graphical data guided the publication bias investigation. Meta-analyses were conducted.

RESULTS

We included 14 RCTs (362 participants), four of which were parallel. Most studies included patients with COPD. High-fat intake decreased VCO₂ [MD = -35.89(95%CI -45.24; -26.21) ml/min; I²=0%], VO₂ [MD= -29.30(95% CI -40.94, -17.66) ml/min; I² = 0%], PaCO₂ [MD = -4.62(95%CI -7.67; -1.58) mmHg; I²=84%], and RQ [MD = -0.08(95%CI -0.09; -0.06); I² = 0%] in the subset of parallel RCTs. In crossover RCTs, there was generally no evidence of effect except for a greater decrease in RQ [MD = -0.09(95%CI -0.12; -0.02); I² = 96%] in favor of high fat intake.

CONCLUSION

High-fat intake resulted in greater reductions ​​of VCO₂ , VO₂ , PaCO₂ , and RQ in adult patients with lung diseases. The certainty of the evidence is very low/ low, and it precludes a specific recommendation on macronutrients contribution to energy intake of these patients. This article is protected by copyright. All rights reserved.

[Nutritional status and dietary intake in patients with chonic obstructive pulmonary disease]

INTRODUCTION

Undernutrition is a predictor of mortality in chronic obstructive pulmonary disease (COPD). The objectives of our study were to assess nutritional intake in COPD and to study its relationship with disease severity.

METHODS

A cross-sectional study that included 66 patients followed for COPD. Patients included had a body composition study and a respiratory and nutritional assessment.

RESULTS

The mean age of the population was 66±9 years. The lean body mass index (LMI) was reduced in 26.1% of patients. It was significantly associated with the GOLD group (P=0.04) and significantly correlated with the forced expiratory volume in the first second (FEV1) (P=0.02) and the distance covered during the six-minute walk test (TM6) (P=0.01). A significant difference was found between the caloric intakes and the different GOLD groups (P=0.04). Mean intakes of calories (P=0.002; r=0.07), protein (P=0.01; r=0.16), carbohydrates (P=0.02; r=0.2) and iron (P=0.01; r=0.13) were significantly correlated with the TM6 results. Caloric intake was significantly correlated with LMI (P=0.01; r=0.16), body mass index (P=0.04; r=0.12), FEV1 (P=0.04; r=-0.12) and GOLD stage (0.002). Similarly, protein intake was significantly correlated with LMI (P=0.001; r=0.11), body mass index (P=0.02; r=0.16), FEV1(%) (P=0.001; r=-0.16) and GOLD stage (P=0.002).

CONCLUSION

Undernutrition in COPD is caused by decreased food intake and increased resting energy expenditure. Adequate intakes of glucose, protein, fibers, vitamins and zinc are associated with improved ventilatory function.

Effect of Bronchoscopic Lung Volume Reduction in Advanced Emphysema on Energy Balance Regulation

BACKGROUND

Hypermetabolism and muscle wasting frequently occur in patients with severe emphysema. Improving respiratory mechanics by bronchoscopic lung volume reduction (BLVR) might contribute to muscle maintenance by decreasing energy requirements and alleviating eating-related dyspnoea.

OBJECTIVE

The goal was to assess the impact of BLVR on energy balance regulation.

DESIGN

Twenty emphysematous subjects participated in a controlled clinical experiment before and 6 months after BLVR. Energy requirements were assessed: basal metabolic rate (BMR) by ventilated hood, total daily energy expenditure (TDEE) by doubly labelled water, whole body fat-free mass (FFM) by deuterium dilution, and physical activity by accelerometry. Oxygen saturation, breathing rate, and heart rate were monitored before, during, and after a standardized meal via pulse oximetry and dyspnoea was rated.

RESULTS

Sixteen patients completed follow-up, and among those, 10 patients exceeded the minimal clinically important difference of residual volume (RV) reduction. RV was reduced with median (range) 1,285 mL (-2,430, -540). Before BLVR, 90% of patients was FFM-depleted despite a normal BMI (24.3 ± 4.3 kg/m2). BMR was elevated by 130%. TDEE/BMR was 1.4 ± 0.2 despite a very low median (range) daily step count of 2,188 (739, 7,110). Following BLVR, the components of energy metabolism did not change significantly after intervention compared to before intervention, but BLVR treatment decreased meal-related dyspnoea (4.1 vs. 1.7, p = 0.019).

CONCLUSIONS

Impaired respiratory mechanics in hyperinflated emphysematous patients did not explain hypermetabolism. Clinical Trial Registry Number: NCT02500004 at www.clinicaltrial.gov.

Nutritional supplementation during pulmonary rehabilitation in COPD: A systematic review

Uptake of nutritional supplementation during pulmonary rehabilitation (PR) for people with chronic obstructive pulmonary disease (COPD) has been limited by an absence of rigorous evidence-based studies supporting use. The objective was to report and summarise the current evidence supporting the use of nutritional supplementation to improve outcomes during PR in stable COPD patients. A systematic search was conducted up to 7 August 2019 (registration number CRD42018089142). The preferred reporting items for systematic reviews and meta-analyses guidelines were used. Six databases were included: Medical Literature Analysis and Retrieval System Online or MEDLARS Online, Allied and Complementary Medicine Database, the Cochrane Database of Systematic Reviews, Excerpta Medica dataBASE, Cumulative Index of Nursing and Allied Health Literature and Web of Science. This systematic search generated 580 initial matches, of which 22 studies (917 COPD participants) met the pre-specified criteria and were included. Sixteen of 19 studies that used nutritional supplements in addition to PR did not show additional benefit compared to PR alone when measuring exercise capacity. Nutritional supplements significantly increased body weight in 7 of 11 studies. Body mass index increased significantly in two of six studies. Handgrip strength did not improve, while quadriceps muscle strength significantly improved in 3 of 11 studies. Four of eight studies showed a significant improvement in inspiratory muscle function. Only 2 of 14 studies demonstrated a significant improvement in quality of life with supplementation in addition to PR. There remains insufficient evidence on the effect of nutritional supplementation on improving outcomes during PR in patients with COPD due to heterogeneity in supplements, outcome measures and PR programmes. Therefore, controversy remains and further research is needed.

Association Between Dietary Nutrient Intake and Chronic Obstructive Pulmonary Disease Severity: A Nationwide Population-Based Representative Sample

Several nutrients have been suggested to protect against airway destruction via antioxidant activity. The present study aimed to evaluate the association between disease severity and dietary nutrient intake in chronic obstructive pulmonary disease (COPD) patients using the Korea National Health and Nutrition Examination Survey. Of the 22,948 participants, 702 patients (418 men and 284 women) with COPD, who were defined as the fifth percentile from a reference population were selected. The severity of airflow limitation was measured by the predicted percentage of forced expiratory volume in 1 second (FEV₁%). The Jonckheere-Terpstra test was used to evaluate the dose-dependent association between nutrient intake and disease severity. Multivariate linear regression analysis was used to evaluate the relationship between dietary nutrient intake and predicted FEV₁%. Vitamin A intake showed a positive association with FEV₁% in men in a model adjusted for covariates. Carbohydrate, protein, fiber, thiamin, riboflavin, niacin, and vitamin C intake were significantly associated with decreased disease severity in elderly men (aged ≥60 years). On the contrary, statistical significance was not observed for all the nutrients in women. In conclusion, intake of carbohydrate, protein, fiber, thiamin, riboflavin, niacin, and vitamin C was associated with decreased severity of airway impairment in elderly men with COPD. Our results are in line with those of previous studies into the importance of nutritional status in airway disease. A longitudinal study is required to clarify the mechanisms underlying the association between dietary nutrient intake and COPD severity.

Effect of two different nutritional supplements on postprandial glucose response and energy- and protein intake in hospitalised patients with COPD: A randomised cross-over study

INTRODUCTION

Oral nutrition support is frequently used in treatment of malnutrition in patients with chronic obstructive pulmonary disease (COPD). Considering the use of corticoidsteroids in patients with COPD, little is known about the effect on postprandial glucose response and if they might interfere with glucose control. Our aims were to compare the effect of a liquid oral nutritional supplement (ONS) and semi solid inbetween meal snack (snack) on postprandial glucose and energy- and protein intake, and to compare the effect of timing of each intervention on postprandial glucose and energy- and protein intake.

METHODS

Patients with COPD (n = 17) admitted to the Department of Pulmonary Medicine, Iceland and defined as at low or medium nutritional risk (score 0-3) were recruited. In a randomised cross-over design, subjects consumed ONS or snack either in a fasting state (study 1) or following breakfast (study 2) and postprandial glucose responses were assessed at regular intervals for two hours (t = 15, t = 30, t = 45, t = 60, t = 90, t = 120 min). Energy- and protein intake was estimated using a validated plate diagram sheet. Wilcoxon Signed-Rank test was used to compare the two interventions.

RESULTS

In study 2, following breakfast, postprandial glucose was significantly higher after consuming ONS than the snack after 60 min (9.7 ± 2.4 mmol/L vs. 8.2 ± 3.2 mmol/L, p = 0.013 and 120 min 9.2 ± 3.2 mmol/L vs. 7.9 ± 2.4 mmol/L, p = 0.021, respectively). No difference was found in postprandial glucose concentrations between ONS and the snack when consumed after overnight fasting (study 1). No difference in energy or protein intake from hospital food was seen between supplement types neither in study 1 or 2.

CONCLUSION

Lower postprandial glucose concentrations were associated with the snack compared to ONS when taken after a meal compared to either type directly after overnight fasting. The clinical relevance of higher postprandial blood glucose after consuming a liquid ONS after breakfast compared with a semi solid snack needs to be studied further.

Nutrition support in hospitalised adults at nutritional risk

BACKGROUND

The prevalence of disease-related malnutrition in Western European hospitals is estimated to be about 30%. There is no consensus whether poor nutritional status causes poorer clinical outcome or if it is merely associated with it. The intention with all forms of nutrition support is to increase uptake of essential nutrients and improve clinical outcome. Previous reviews have shown conflicting results with regard to the effects of nutrition support.

OBJECTIVES

To assess the benefits and harms of nutrition support versus no intervention, treatment as usual, or placebo in hospitalised adults at nutritional risk.

SEARCH METHODS

We searched Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE (Ovid SP), Embase (Ovid SP), LILACS (BIREME), and Science Citation Index Expanded (Web of Science). We also searched the World Health Organization International Clinical Trials Registry Platform (www.who.int/ictrp); ClinicalTrials.gov; Turning Research Into Practice (TRIP); Google Scholar; and BIOSIS, as well as relevant bibliographies of review articles and personal files. All searches are current to February 2016.

SELECTION CRITERIA

We include randomised clinical trials, irrespective of publication type, publication date, and language, comparing nutrition support versus control in hospitalised adults at nutritional risk. We exclude trials assessing non-standard nutrition support.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane and the Cochrane Hepato-Biliary Group. We used trial domains to assess the risks of systematic error (bias). We conducted Trial Sequential Analyses to control for the risks of random errors. We considered a P value of 0.025 or less as statistically significant. We used GRADE methodology. Our primary outcomes were all-cause mortality, serious adverse events, and health-related quality of life.

MAIN RESULTS

We included 244 randomised clinical trials with 28,619 participants that met our inclusion criteria. We considered all trials to be at high risk of bias. Two trials accounted for one-third of all included participants. The included participants were heterogenous with regard to disease (20 different medical specialties). The experimental interventions were parenteral nutrition (86 trials); enteral nutrition (tube-feeding) (80 trials); oral nutrition support (55 trials); mixed experimental intervention (12 trials); general nutrition support (9 trials); and fortified food (2 trials). The control interventions were treatment as usual (122 trials); no intervention (107 trials); and placebo (15 trials). In 204/244 trials, the intervention lasted three days or more.We found no evidence of a difference between nutrition support and control for short-term mortality (end of intervention). The absolute risk was 8.3% across the control groups compared with 7.8% (7.1% to 8.5%) in the intervention groups, based on the risk ratio (RR) of 0.94 (95% confidence interval (CI) 0.86 to 1.03, P = 0.16, 21,758 participants, 114 trials, low quality of evidence). We found no evidence of a difference between nutrition support and control for long-term mortality (maximum follow-up). The absolute risk was 13.2% in the control group compared with 12.2% (11.6% to 13%) following nutritional interventions based on a RR of 0.93 (95% CI 0.88 to 0.99, P = 0.03, 23,170 participants, 127 trials, low quality of evidence). Trial Sequential Analysis showed we only had enough information to assess a risk ratio reduction of approximately 10% or more. A risk ratio reduction of 10% or more could be rejected.We found no evidence of a difference between nutrition support and control for short-term serious adverse events. The absolute risk was 9.9% in the control groups versus 9.2% (8.5% to 10%), with nutrition based on the RR of 0.93 (95% CI 0.86 to 1.01, P = 0.07, 22,087 participants, 123 trials, low quality of evidence). At long-term follow-up, the reduction in the risk of serious adverse events was 1.5%, from 15.2% in control groups to 13.8% (12.9% to 14.7%) following nutritional support (RR 0.91, 95% CI 0.85 to 0.97, P = 0.004, 23,413 participants, 137 trials, low quality of evidence). However, the Trial Sequential Analysis showed we only had enough information to assess a risk ratio reduction of approximately 10% or more. A risk ratio reduction of 10% or more could be rejected.Trial Sequential Analysis of enteral nutrition alone showed that enteral nutrition might reduce serious adverse events at maximum follow-up in people with different diseases. We could find no beneficial effect of oral nutrition support or parenteral nutrition support on all-cause mortality and serious adverse events in any subgroup.Only 16 trials assessed health-related quality of life. We performed a meta-analysis of two trials reporting EuroQoL utility score at long-term follow-up and found very low quality of evidence for effects of nutritional support on quality of life (mean difference (MD) -0.01, 95% CI -0.03 to 0.01; 3961 participants, two trials). Trial Sequential Analyses showed that we did not have enough information to confirm or reject clinically relevant intervention effects on quality of life.Nutrition support may increase weight at short-term follow-up (MD 1.32 kg, 95% CI 0.65 to 2.00, 5445 participants, 68 trials, very low quality of evidence).

AUTHORS' CONCLUSIONS

There is low-quality evidence for the effects of nutrition support on mortality and serious adverse events. Based on the results of our review, it does not appear to lead to a risk ratio reduction of approximately 10% or more in either all-cause mortality or serious adverse events at short-term and long-term follow-up.There is very low-quality evidence for an increase in weight with nutrition support at the end of treatment in hospitalised adults determined to be at nutritional risk. The effects of nutrition support on all remaining outcomes are unclear.Despite the clinically heterogenous population and the high risk of bias of all included trials, our analyses showed limited signs of statistical heterogeneity. Further trials may be warranted, assessing enteral nutrition (tube-feeding) for different patient groups. Future trials ought to be conducted with low risks of systematic errors and low risks of random errors, and they also ought to assess health-related quality of life.

The Use of Specialized Enteral Formulas in Pulmonary Disease

The relationship between pulmonary disease and nutrition is significant. Malnutrition and its associated adverse pulmonary effects can directly affect outcomes in the individual with pulmonary disease. The use of nutrition support is common for these patients as a supportive or therapeutic measure. Historical reports of adverse respiratory function associated with high parenteral carbohydrate intakes have led to the controversial use of high-fat enteral products in patients with chronic pulmonary dysfunction. The rationale for using this type of formula is that by providing less carbohydrates, carbon dioxide production will be reduced, respiratory quotient will therefore decrease, and a favorable respiratory outcome will result. In the patient with acute respiratory distress syndrome, an inflammatory state exists in which proinflammatory mediators are produced and affect the course of the disease. An enteral formula with modified lipids designed to modulate eicosanoid production and therefore influence the inflammatory cascade is available. This article reviews the rationale for use of modified enteral formulas in both chronic and acute pulmonary disease, reviews the available studies evaluating the efficacy of these formulas, and provides overall recommendations for the use of specialized enteral formulas in individuals with pulmonary disease.

Enteral nutrition formula selection: current evidence and implications for practice

Many new enteral nutrition (EN) formulas have been created over the past several decades with a variety of intended uses. Although each is intended to promote improved outcomes, research is often unclear and, in many cases, conflicting. It is important to note that EN products are considered medical foods by the U.S. Food and Drug Administration and therefore do not have to complete premarket review or approval and are not regulated to the same extent as pharmaceuticals. While standard EN formulas are designed to meet the basic macro- and micronutrient requirements of individuals who cannot meet nutrition needs orally, specialty EN products have been developed to exhibit pharmacologic properties, such as immune-enhancing formulas containing arginine, glutamine, nucleotides, and ω-3 fatty acids. With the vast number of products available, rising costs of healthcare, and the drive toward evidence-based practice, it is imperative that clinicians carefully consider research regarding use of specialty formulas, paying close attention to the quality, patient population, clinical end points, and cost to patient and/or facility.

Nutrition as a metabolic modulator in COPD

COPD is an important global health problem. In addition to pulmonary impairment, systemic inflammation, musculoskeletal abnormalities, and cardiovascular comorbidity influence disease burden and mortality risk. Body weight and body composition are important discriminants in classifying disease heterogeneity. The rationale for and efficacy of caloric supplementation in preventing and treating involuntary weight loss is currently well established. For maintenance of muscle and bone tissue, appropriately timed, high-quality protein intake and addressing vitamin D deficiency must be considered. Specific nutrients (eg, n-3 polyunsaturated fatty acids and polyphenolic compounds) may have the pharmacologic potential to boost decreased muscle mitochondrial metabolism and enhance impaired physical performance, particularly when the metabolic stimulus of physical activity alone is limited. At this stage, evidence is insufficient to support an intake of high doses of single nutritional supplements to modulate respiratory pathology, but some small studies have identified micronutrient modulation via the diet as a promising intervention.

Energy and protein intakes of hospitalised patients with acute respiratory failure receiving non-invasive ventilation

BACKGROUND & AIM

Nutritional intake of patients in acute respiratory failure receiving non-invasive ventilation has not previously been described, and no protocols have been developed to guide practice to optimise nutritional status. We aimed to measure energy and protein intakes of patients in acute respiratory failure requiring non-invasive ventilation receiving standard hospital nutritional care.

METHODS

Food and fluid intake forms were completed by nursing staff for all meals and mid meals for patients admitted with respiratory failure commencing on non-invasive ventilation. Intake was converted from quartiles of food consumed into energy and protein to enable comparison with estimated daily requirements using descriptive statistics. Multinomial stepwise regression analysis was used to determine factors associated with inadequate protein and energy intake.

RESULTS

Over 283 total days of intake, 36 participants (67% female, aged 65 ± 9 years) achieved on average 1434 ± 627 kcal and 63 ± 29 g protein daily. Overall, 28 patients (78%, 95% CI: 61-90%) met less than 80% of estimated energy requirements and 27 patients (75%, 95% CI: 58-88%) met less than 80% of estimated protein requirements. Being fed orally, longer time on non-invasive ventilation and higher BMI were associated with poorer intakes. Better nutritional status on admission and measuring intake closer to hospital discharge was associated with improved intakes.

CONCLUSION

Patients with acute respiratory failure requiring non-invasive ventilation often had inadequate oral intake, particularly with increasing time on non-invasive ventilation, and earlier during their hospital admission. Development of protocols to optimise nutritional intake for these patients may improve outcomes and reduce regular readmission rates.

Nutritional supplement products: Does the label information influence purchasing decisions for the physically active?

Background

The increase in sales of nutritional supplement globally can be attributed, in part, to aggressive marketing by manufacturers, rather than because the nutritional supplements have become more effective. Furthermore, the accuracy of the labelling often goes unchallenged. Therefore, any effects of the supplement, may be due to contaminants or adulterants in these products not reflected on the label.

Methods

A self-administered questionnaire was used to determine how consumers of nutritional supplements acquired information to assist their decision-making processes, when purchasing a product. The study was approved by the University of Cape Town, Faculty of Health Sciences Human Research Ethics Committee. The questionnaire consisted of seven, closed and open-ended questions. The participants were asked to respond to the questions according to a defined list of statements. A total of 259 participants completed and returned questionnaires. The data and processing of the returned questionnaires was captured using Windows-based Microsoft® Office Excel 2003 SP 1 (Excel © 1985–2003 Microsoft Corporation). Statistica Version 10 (copyright © Stat Soft, Inc. 1984–2011) was used to calculate the descriptive statistics.

Results

The main finding of the study was that nearly 70% of the respondents who purchased supplements were strongly influenced by container label information that stipulated that the nutritional supplement product is free of banned substances. The second finding was that just over 50% of the respondents attached importance to the quality of the nutritional supplement product information on the container label. The third finding was that about 40% of the respondents were strongly influenced by the ingredients on the labels when they purchased nutritional supplements.

Conclusion

This study, (i) identifies short-comings in current labelling information practices, (ii) provides opportunities to improve label and non-label information and communication, and, (iii) presents the case for quality assurance laboratory “screening testing” of declared and undeclared contaminants and/or adulterants, that could have negative consequences to the consumer.

Nutritional targets to enhance exercise performance in chronic obstructive pulmonary disease

PURPOSE OF REVIEW

This review presents current knowledge regarding the rationale and efficacy of nutrition as an ergogenic aid to enhance the effects of exercise and training in chronic obstructive pulmonary disease (COPD).

RECENT FINDINGS

Altered body composition and skeletal muscle dysfunction in COPD suggest that exercise capacity can be targeted via several metabolic routes. Muscle metabolic alterations in COPD include a reduced oxidative metabolism and enhanced susceptibility for oxidative stress. Muscle wasting may be associated with deficiencies of vitamin D and low branched-chain amino acid levels. Exercise training is of established benefit in COPD but clear-cut clinical trial evidence to support the performance enhancing effect of nutritional intervention is lacking. One randomized controlled trial suggested that augmentation of training with polyunsaturated fatty acids may improve exercise capacity. Conflicting results are reported on dietary creatine supplementation in patients with COPD receiving pulmonary rehabilitation and results from acute intervention studies do not directly imply long-term effects of glutamate or glutamine supplementation as an ergogenic aid in COPD. Recent data indicate that not only muscle but also visceral fat may be an important additional target for combined nutrition and exercise intervention in COPD to improve physical performance and decrease cardiometabolic risk.

SUMMARY

There is a clear need for adequately powered and controlled intervention and maintenance trials to establish the role of nutritional supplementation in the enhancement of exercise performance and training and the wider management of the systemic features of the disease.

Nutritional support in chronic obstructive pulmonary disease: a systematic review and meta-analysis

BACKGROUND

The efficacy of nutritional support in the management of malnutrition in chronic obstructive pulmonary disease (COPD) is controversial. Previous meta-analyses, based on only cross-sectional analysis at the end of intervention trials, found no evidence of improved outcomes.

OBJECTIVE

The objective was to conduct a meta-analysis of randomized controlled trials (RCTs) to clarify the efficacy of nutritional support in improving intake, anthropometric measures, and grip strength in stable COPD.

DESIGN

Literature databases were searched to identify RCTs comparing nutritional support with controls in stable COPD.

RESULTS

Thirteen RCTs (n = 439) of nutritional support [dietary advice (1 RCT), oral nutritional supplements (ONS; 11 RCTs), and enteral tube feeding (1 RCT)] with a control comparison were identified. An analysis of the changes induced by nutritional support and those obtained only at the end of the intervention showed significantly greater increases in mean total protein and energy intakes with nutritional support of 14.8 g and 236 kcal daily. Meta-analyses also showed greater mean (±SE) improvements in favor of nutritional support for body weight (1.94 ± 0.26 kg, P < 0.001; 11 studies, n = 308) and grip strength (5.3%, P < 0.050; 4 studies, n = 156), which was not shown by ANOVA at the end of the intervention, largely because of bias associated with baseline imbalance between groups.

CONCLUSION

This systematic review and meta-analysis showed that nutritional support, mainly in the form of ONS, improves total intake, anthropometric measures, and grip strength in COPD. These results contrast with the results of previous analyses that were based on only cross-sectional measures at the end of intervention trials.

Protein and energy supplementation in elderly people at risk from malnutrition

BACKGROUND

Evidence for the effectiveness of nutritional supplements containing protein and energy, often prescribed for older people, is limited. Malnutrition is more common in this age group and deterioration of nutritional status can occur during illness. It is important to establish whether supplementing the diet is an effective way of improving outcomes for older people at risk from malnutrition.

OBJECTIVES

This review examined trials for improvement in nutritional status and clinical outcomes when extra protein and energy were provided, usually as commercial 'sip-feeds'.

SEARCH STRATEGY

We searched The Cochrane Library, MEDLINE, EMBASE, Healthstar, CINAHL, BIOSIS, CAB abstracts. We also hand searched nutrition journals and reference lists and contacted 'sip-feed' manufacturers.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials of oral protein and energy supplementation in older people, with the exception of groups recovering from cancer treatment or in critical care.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trials prior to inclusion and independently extracted data and assessed trial quality. Authors of trials were contacted for further information as necessary.

MAIN RESULTS

Sixty-two trials with 10,187 randomised participants have been included in the review. Maximum duration of intervention was 18 months. Most included trials had poor study quality. The pooled weighted mean difference (WMD) for percentage weight change showed a benefit of supplementation of 2.2% (95% confidence interval (CI) 1.8 to 2.5) from 42 trials. There was no significant reduction in mortality in the supplemented compared with control groups (relative risk (RR) 0.92, CI 0.81 to 1.04) from 42 trials. Mortality results were statistically significant when limited to trials in which participants (N = 2461) were defined as undernourished (RR 0.79, 95% CI 0.64 to 0.97).The risk of complications was reduced in 24 trials (RR 0.86, 95% CI 0.75 to 0.99). Few trials were able to suggest any functional benefit from supplementation. The WMD for length of stay from 12 trials also showed no statistically significant effect (-0.8 days, 95% CI -2.8 to 1.3). Adverse effects included nausea or diarrhoea.

AUTHORS' CONCLUSIONS

Supplementation produces a small but consistent weight gain in older people. Mortality may be reduced in older people who are undernourished. There may also be a beneficial effect on complications which needs to be confirmed. However, this updated review found no evidence of improvement in functional benefit or reduction in length of hospital stay with supplements. Additional data from large-scale multi-centre trials are still required.

Nutritional aspects of chronic obstructive pulmonary disease

It is clear that being underweight is a poor prognostic sign in chronic obstructive pulmonary disease (COPD). It is also clear that undernutrition is at least in part associated with the severity of airflow obstruction. While both weight and body mass index are useful screening tools in the initial nutritional evaluation, fat-free mass (FFM) may be a better marker of undernutrition in patients with COPD. The causes of cachexia in patients with COPD are multifactorial and include decreased oral intake, the effect of increased work of breathing due to abnormal respiratory mechanics, and the effect of chronic systemic inflammation. Active nutritional supplementation in undernourished patients with COPD can lead to weight gain and improvements in respiratory muscle function and exercise performance. However, long-term effects of nutritional supplementation are not clear. In addition, the optimal type of nutritional supplementation needs to be explored further. The role of novel forms of treatment, such as androgens or appetite stimulants designed to increase FFM, also needs to be further studied. Thus, in the absence of definitive data, it cannot be said that long-term weight gain, either using enhanced caloric intake, with or without anabolic steroids or appetite stimulants, offers survival or other benefits to patients with COPD. However, there are indications from single-center trials that this is an avenue well worth exploring.

Multidisciplinary care of the patient with chronic obstructive pulmonary disease

The National Emphysema Treatment Trial used a multidisciplinary team approach to implement the maximum medical care protocol, including adjustment of medications and outpatient pulmonary rehabilitation for all patients and nutritional and psychological counseling as needed. This article discusses the benefits of such an approach in the care of the patient with chronic obstructive pulmonary disease. Team member roles complement each other and contribute to the goal of providing the highest-quality medical care. The primary focus of the team is to reinforce the medical plan and to provide patient education and support. This article reviews the elements of the initial patient assessment and the functional and nutritional assessment. Patient education focuses on medication use, recognition and management of chronic obstructive pulmonary disease exacerbation symptoms, smoking cessation, advance directives, and travel.

Dietary supplementation by Japanese patients with chronic obstructive pulmonary disease

OBJECTIVES

To investigate the prevalence and type of dietary supplements taken by Japanese patients with chronic obstructive pulmonary disease (COPD) and factors affecting their use.

DESIGN

Cross-sectional study by face-to-face interviews.

SETTING

Six hospitals in central Japan.

PARTICIPANTS

Of the 300 referred COPD patients aged between 50 and 75 years, 278 eligible participants (244 men and 34 women) with complete data were available for analysis.

MAIN OUTCOME MEASURES

Prevalence of supplement use, dietary supplement categories (multivitamin, beta-carotene, vitamin C, vitamin E, and miscellaneous).

RESULTS

Overall, 42% of participants were dietary supplement users taking at least one category of supplements weekly; the prevalence being higher for female (47%) than male patients (41%). The most common supplements consumed were energy drink for men (11.1%), and multivitamin (11.8%) and vinegar (11.8%) for women. Dietary supplementation was found to be affected by age (p=0.04), COPD severity (p=0.03) and presence of co-morbidity (p=0.03). Older patients over 60 years were more likely to take dietary supplements (odds ratio (OR) 2.44, 95% CI 1.03-5.80), whereas severe COPD patients (OR 0.41, 95% CI 0.18-0.95) and those with a co-morbidity (OR 0.54, 95% CI 0.32-0.94) tended not to use.

CONCLUSIONS

Dietary supplements are popular for patients with COPD especially among older patients. The findings are important to clinical trials and experimental interventions advocating nutritional supplementation therapy for pulmonary rehabilitation.

An evaluation of the safety and efficacy of an anti-inflammatory, pulmonary enteral formula in the treatment of pediatric burn patients with respiratory failure

Respiratory failure is associated with a high mortality rate in burned children. Recently, a specialized pulmonary enteral formula (SPEF) was commercially introduced as an adjunct intervention in acute lung injury management. SPEF contains condition-specific nutrients to modulate the inflammatory response. The study examined SPEF impact in critically ill, pediatric burn patients with respiratory failure. Medical records of acute burn patients admitted December 1997 to October 2006 were reviewed for SPEF treatment. Respiratory and renal indices were compared on the first and final days of SPEF use. Nineteen patients with respiratory failure received SPEF for a mean of 10.8 +/- 0.9 days during their acute burn course. Mean age was 5.3 +/- 1.5 years. Mean total body surface area burn was 44.3 +/- 5.4% with 32.5 +/- 6.4% full thickness. Patients were admitted 2.3 +/- 0.9 days postburn. Significant improvements in peak pressure, PEEP, FiO2, P:F ratio, Pco2, Po2, and ETco2 were noted. Seventeen of the 19 patients survived despite the fact that 9 of the 19 patients developed severe barotrauma requiring multiple tube thoracotomies, and all 19 had extremely poor prognoses at SPEF initiation. Adult SPEF formula for critically ill, pediatric burn patients with respiratory failure is safe and well tolerated. SPEF seems to facilitate recovery from acute lung injury as evidenced by improvements in oxygenation and pulmonary compliance.

Optimizing oral nutritional drink supplementation in patients with chronic obstructive pulmonary disease

Nutritional support is indicated in some patients with chronic obstructive pulmonary disease to restore nutritional status and improve functional capacity. However, the efficacy of nutritional supplements is sometimes disappointing, partly owing to a compensatory drop in habitual food intake. We retrospectively studied the effect of nutritional drink supplements, differing in portion size and energy content, on weight gain and body composition. Thirty-nine patients with stable chronic obstructive pulmonary disease, participating in an 8-week pulmonary rehabilitation programme and eligible for nutritional support, were studied. Group A (n19) received three portions of 125 ml (2380 kJ), whereas group B (n20) received three portions of 200 ml (3350 kJ) daily. The macronutrient composition of the regimens was similar (20 % protein, 60 % carbohydrates and 20 % fat). Lung function, body weight, body composition (by bio-electrical impedance analysis), habitual dietary intake (by dietary history) and resting energy expenditure (by ventilated hood) were determined. Weight gain was compared with expected weight as predicted by a computer simulation model. Although patients in both groups significantly increased in weight, this increase was higher in group A (A, 3·3 (sd 1·9) kg; B, 2·0 (sd 1·2) kg;P=0·019), while receiving less energy. The observed weight gain in group A was similar to that expected, but in group B it was lower than expected (P<0·001). In both groups, fat-free mass and fat mass were gained in a ratio of 2:1, fat-free mass increasing primarily during the first 4 weeks. This study illustrates that there might be an optimum for the portion size of nutritional drink supplements in chronic obstructive pulmonary disease and that more is not always better.

Nutritional modulation as part of the integrated management of chronic obstructive pulmonary disease

Weight loss is a frequent complication in patients with chronic obstructive pulmonary disease (COPD) and is a determining factor for functional capacity, health status and mortality. Weight loss in COPD is a consequence of an inbalance between increased energy requirements and dietary intake. Both metabolic and mechanical inefficiency may contribute to elevated energy expenditure during physical activity, while systemic inflammation has been associated with hypermetabolism at rest. Disease-specific symptoms and systemic inflammation may impair appetite and dietary intake. Altered intermediary metabolism may cause disproportionate wasting of fat-free mass in some patients. A combination of nutritional support and exercise as an anabolic stimulus appears to be the best approach to obtaining marked functional improvement. Patients responding to this treatment even demonstrated a decreased mortality. The effectiveness of anti-catabolic modulation requires further investigation.

Living with chronic obstructive pulmonary disease (COPD): Part II. RNs? experience of nursing care for patients with COPD and impaired nutritional status

This study is the second part of a project with the main purpose of obtaining a deeper understanding of the consequences of living with chronic obstructive pulmonary disease (COPD) concerning meal-related situations and an impaired nutritional status. COPD is a slowly progressive lung disease that results in several complications, including malnutrition. Nutritional status is an important part of COPD treatment, and there are criteria recommended for nutritional assessment and interventions among patients with COPD. Despite this, patients with extreme malnutrition and unnoticed weight loss are reported. The aim of the study was to investigate how Registered Nurses (RNs) in primary care describe nutritional assessment practices and interventions in COPD patients with impaired nutritional status. An interview approach using semistructured questions and case vignettes was chosen. The sample included 19 RNs working specifically with COPD patients. Data from interviews were analysed using qualitative content analysis, and nine categories corresponding to the aim were identified. The RNs reported that their assessment of nutritional status was based largely on intuition. Assessment also included detection of the patients' current beliefs and being sensible about information provision - When and How. Interventions were supportive eating interventions, practical and cognitive participation, and making patients aware of the illness trajectory. An overall category that influenced nursing was respecting patients' feelings of shame and guilt about a self-inflicted disease. It seems that RNs use intuition because of a lack of knowledge of systematic methods of nutritional assessment. The findings also indicate that the RNs attempted to build a relationship of trust with the patients rather than provide early information on sensitive topics (e.g. nutritional information). The study reports areas of nursing care for COPD patients that must be improved in the future.

Dyspnea Management in Lung Cancer: Applying the Evidence From Chronic Obstructive Pulmonary Disease

PURPOSE/OBJECTIVES

To provide an overview of mechanisms of dyspnea and causes of dyspnea in chronic obstructive pulmonary disease (COPD) and lung cancer and to critically review current pharmacologic and nonpharmacologic management of dyspnea for COPD and lung cancer.

DATA SOURCES

Published articles, abstracts, textbooks, and the authors' personal experiences with dyspnea management in COPD and lung cancer.

DATA SYNTHESIS

The causes of dyspnea in cancer are more varied than the causes of dyspnea in COPD; however, many are similar, thus providing the justification for recommending best practice from COPD research to be used in lung cancer. Dyspnea in both diseases is treated by corticosteroids, bronchodilators, antianxiety drugs, local anesthetics, and oxygen. However, when dyspnea is severe, morphine is the first choice. Using specific breathing techniques, positioning, energy conservation, exercise, and some dietary modifications and nutrient supplements can help with dyspnea management.

CONCLUSIONS

Pharmacologic and nonpharmacologic management of dyspnea in COPD can be applied to dyspnea related to lung cancer. Further research in the management of dyspnea in lung cancer is required, particularly controlled studies with larger sample sizes, to determine the effectiveness of the application of COPD dyspnea management in lung cancer.

IMPLICATIONS FOR NURSING

Previous studies provide a guideline for applying dyspnea management for COPD to cancer. The theoretical frameworks used in previous studies can be modified for conducting further study.

ESPEN Guidelines on Enteral Nutrition: Cardiology and Pulmonology

These guidelines are intended to give evidence-based recommendations for the use of enteral nutrition (EN) in patients with chronic heart failure (CHF) and chronic obstructive pulmonary disease (COPD). They were developed by an interdisciplinary expert group in accordance with officially accepted standards and are based on all relevant publications since 1985. They have been discussed and accepted in a consensus conference. EN by means of oral nutritional supplements (ONS) or tube feeding (TF) enables nutritional intake to be maintained or increased when normal oral intake is inadequate. No data are yet available concerning the effects of EN on cachexia in CHF patients. However, EN is recommended to stop or reverse weight loss on the basis of physiological plausibility. In COPD patients, EN in combination with exercise and anabolic pharmacotherapy has the potential to improve nutritional status and function. Frequent small amounts of ONS are preferred in order to avoid postprandial dyspnoea and satiety as well as to improve compliance.

Living with chronic obstructive pulmonary disease: Part I. Struggling with meal-related situations: experiences among persons with COPD

Reduced nutritional intake with low and decreased body weight can be a component of normal ageing. There is, however, also a greater risk for reduced nutritional intake within certain diagnoses, especially for chronic diseases. Malnutrition in chronic obstructive pulmonary disease (COPD) is caused by many factors. The relationship between COPD and low values of body mass index (BMI) is a known independent risk for mortality. For optimal support and care with special focus on nutritional status and interventions, caregivers need more knowledge about the meal-related situations (i.e. shopping for food, cooking and eating) of COPD patients. The aim of this study was to describe experiences of meal-related situations as viewed from the individual's perspective. The sample included eight women and five men with COPD recruited from five primary health clinics. The participants' average age was 68.9 years, with values of forced expiratory volume in 1 second (FEV(1) percentage) ranging from 18 to 69 and BMI values from 15 to 40. A descriptive design with qualitative interviews and self-reported diaries were used and the data were later analysed using content analysis. Findings showed consistency between informants' COPD, nutritional status and descriptions of experiences in meal-related situations. Findings were disease-specific but were also found to be general- and age-related. Respondents described physical influences and positive and negative feelings in their meal-related situations. Feelings of dependence, level of activity, transport of food, having company or being alone, appetite, hunger and need of time were also mentioned. Most research reports reduced nutritional status from a medical perspective. To our knowledge, no study has reported the positive and negative feelings that arise when eating in persons with COPD. Malnutrition for persons with COPD is not only caused by eating difficulties: eating is an integral part of social situations as shown in this study.

Protein and energy supplementation in elderly people at risk from malnutrition

BACKGROUND

Evidence for the effectiveness of nutritional supplements containing protein and energy, which are often prescribed for older people, is limited. Furthermore malnutrition is more common in this age group and deterioration of nutritional status can occur during illness. It is important to establish whether supplementing the diet is an effective way of improving outcomes for older people at risk from malnutrition.

OBJECTIVES

This review examined the evidence from trials for improvement in nutritional status and clinical outcomes when extra protein and energy were provided, usually in the form of commercial 'sip-feeds'.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Healthstar, CINAHL, BIOSIS, CAB abstracts. We also hand searched nutrition journals and reference lists and contacted 'sip-feed' manufacturers. Date of most recent search: March 2004.

SELECTION CRITERIA

Randomised controlled trials and quasi-randomised controlled trials of oral protein and energy supplementation in older people with the exception of groups recovering from cancer treatment or in critical care.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trials prior to inclusion and independently extracted data and assessed trial quality. Authors of trials were contacted for further information as necessary.

MAIN RESULTS

Forty-nine trials with 4790 randomised participants have been included in the review. Most included trials had poor study quality. The pooled weighted mean difference [WMD] for percentage weight change showed a benefit of supplementation of 2.3% (95% confidence interval (CI) 1.9 to 2.7) from 34 trials. There was a reduced mortality in the supplemented compared with control groups (relative risk (RR) 0.74, CI 0.59 to 0.92) from 32 trials. The risk of complications from 14 trials showed no significant difference (RR 0.95, 95% CI 0.81 to 1.11). Few trials were able to suggest any functional benefit from supplementation. The pooled weighted mean difference (WMD) for length of stay from 10 trials also showed no statistically significant effect (WMD -1.98 days, 95% CI -5.20 to 1.24).

AUTHORS' CONCLUSIONS

Supplementation produces a small but consistent weight gain in older people. There may also be a beneficial effect on mortality. However, there was no evidence of improvement in clinical outcome, functional benefit or reduction in length of hospital stay with supplements. Additional data from large-scale multi-centre trials are still required.

Dietary change, nutrition education and chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is a prevalent and serious condition. Nutrition might play a role in COPD prevention and is definitely important in COPD management. There are some indications from epidemiological studies that dietary factors such as ample consumption of fruit and fish may decrease COPD risk. The available evidence is, however, not substantial enough to warrant dietary recommendations for primary prevention of COPD. Substantial evidence does point to the conclusion that, regardless of disease severity, weight loss is related to decreased exercise capacity, health status and mortality as well as to increased morbidity among patients with moderate to severe COPD. Current nutritional support strategies have primarily focussed on treatment of severely underweight and disabled patients. In an in-patient setting or when incorporated in a pulmonary rehabilitation programme, nutritional support has proved effective in inducing weight gain and related functional improvements. However, such interventions are only feasible for a selected group of patients and are very laborious. Therefore, opportunities for dietary and nutrition interventions in COPD management should be explored, aiming at early detection, prevention and early treatment of involuntary weight loss. This means expanding the target group to include COPD out-patients and primary care patients before they have become underweight, and putting more emphasis on dietary change than on medically prescribed supplementation. Successful intervention assumes (voluntary) adjustment of dietary behaviour, and health professionals may play an essential role in encouraging patients to make and maintain these changes. Achieving dietary change among COPD patients may require a combination of diet counselling and self-management. A model for such a combination is presented.

Nutritional enhancement of exercise performance in chronic obstructive pulmonary disease: a randomised controlled trial

BACKGROUND

Pulmonary rehabilitation is effective in improving exercise performance and health status in chronic obstructive pulmonary disease (COPD). However, the role of nutritional support in the enhancement of the benefits of exercise training has not been explored. A double blind, randomised, controlled trial of carbohydrate supplementation was undertaken in patients attending outpatient pulmonary rehabilitation.

METHODS

85 patients with COPD were randomised to receive a 570 kcal carbohydrate rich supplement or a non-nutritive placebo daily for the duration of a 7 week outpatient pulmonary rehabilitation programme. Primary outcome measures were peak and submaximal exercise performance using the shuttle walk tests. Changes in health status, body composition, muscle strength, and dietary macronutrient intake were also measured.

RESULTS

Patients in both the supplement and placebo groups increased shuttle walking performance and health status significantly. There was no statistically significant difference between treatment groups in these outcomes. Patients receiving placebo lost weight whereas supplemented patients gained weight. In well nourished patients (BMI >19 kg/m(2)) improvement in incremental shuttle performance was significantly greater in the supplemented group (mean difference between groups: 27 (95% CI 1 to 53) m, p<0.05). Increases in incremental shuttle performance correlated with increases in total carbohydrate intake.

CONCLUSIONS

When universally prescribed, carbohydrate supplementation does not enhance the rehabilitation of patients with COPD. This study suggests that exercise training results in negative energy balance that can be overcome by supplementation and that, in selected patients, this may improve the outcome of training. The finding of benefit in well nourished patients may suggest a role for nutritional supplementation beyond the treatment of weight loss in COPD.

Chronic obstructive pulmonary disease and malnutrition: why are we not winning this battle?

OBJECTIVES: To review the mechanisms involved in the origin of malnutrition in patients with chronic obstructive pulmonary disease (COPD), and to make a systematic review of randomized controlled studies, to clarify the contribution of nutritional supplementation in patients with stable COPD. METHOD: A systematic review of articles published in the field of nutrition, in any language and from several sources, including Medline, Embase, Cinahl, and the Cochrane Registry on COPD, as well as studies presented at congresses in the US and Europe. RESULTS: Studies on nutritional supplementation for more than two weeks showed a very small effect, not reaching statistical significance. A linear regression study found that old age, relative anorexia, and high inflammatory response are associated with non-response to nutritional therapy. CONCLUSION: Currently, there is no evidence that nutritional supplementation is truly effective in patients with COPD. Factors associated with non-response suggest a relationship with the degree of inflammation, including high TNF-alpha levels. Measuring inflammation markers may be useful to determine prognosis and adequate therapy. Treatment with anti-inflammatory cytokines or cytokine inhibitors seems promising for the future.

Efficacy of nutritional supplementation therapy in depleted patients with chronic obstructive pulmonary disease

OBJECTIVE

Weight loss and muscle wasting adversely affect morbidity and mortality in patients with chronic obstructive pulmonary disease (COPD). Maintenance systemic glucocorticosteroids, prescribed in a substantial number of patients, further contribute to muscle weakness. We investigated the efficacy of oral nutritional supplementation therapy in depleted patients with COPD.

METHODS

The therapy consisted of daily two to three oral liquid nutritional supplements (mean +/- standard deviation: 2812 +/- 523 kJ/24 h) incorporated into an 8-wk inpatient pulmonary rehabilitation program in 64 (49 men) depleted patients with COPD. Endpoints were body weight, fat-free mass by bioelectrical impedance analysis, respiratory and peripheral muscle function (maximal inspiratory mouth pressure and handgrip strength, respectively), exercise performance (incremental bicycle ergometry), and disease-specific health status by St. George's Respiratory Questionnaire. Forty-eight percent of the patients were treated with low-dose oral glucocorticosteroids as maintenance medication (dose equivalent to 7.6 +/- 2.5 mg of methylprednisolone per day).

RESULTS

Increases in body weight (2.1 +/- 2.1 kg, P < 0.001) and fat-free mass (1.1 +/- 2.0 kg, P < 0.001) were seen. Further, maximal inspiratory mouth pressure (4 +/- 10 cm of H(2)O, P = 0.001), handgrip strength (1.2 +/- 3.1 kg, P = 0.004), and peak workload (7 +/- 11 W, P = 0.001) significantly improved. Clinically significant improvements in the items symptoms (9 +/- 16 points, P < 0.001) and impact (4 +/- 15 points, P = 0.043) of St. George's Respiratory Questionnaire were achieved. Oral glucocorticosteroid treatment significantly impaired the response to nutritional supplementation therapy with respect to maximal inspiratory mouth pressure, peak workload, and St. George's Respiratory Questionnaire symptom score.

CONCLUSIONS

Nutritional supplementation therapy implemented in a pulmonary rehabilitation program was effective in depleted patients with COPD. However, oral glucocorticosteroid treatment attenuated the anabolic response to nutritional supplementation.

Pulmonary cachexia

Weight loss is a frequent complication in patients with chronic obstructive pulmonary disease (COPD) and is a determining factor of functional capacity, health status, and mortality. Weight loss in COPD is a consequence of increased energy requirements unbalanced by dietary intake. Both metabolic and mechanical inefficiency contribute to the elevated energy expenditure during physical activity, while systemic inflammation is a determinant of hypermetabolism at rest. A disbalance between protein synthesis and protein breakdown may cause a disproportionate depletion of fat-free mass in some patients. Nutritional support is indicated for depleted patients with COPD because it provides not only supportive care, but direct intervention through improvement in respiratory and peripheral skeletal muscle function and in exercise performance. A combination of oral nutritional supplements and exercise or anabolic stimulus appears to be the best treatment approach to obtaining significant functional improvement. Patients responding to this treatment even demonstrated a decreased mortality. Poor response was related to the effects of systemic inflammation on dietary intake and catabolism. The effectiveness of anticatabolic modulation requires further investigation.