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response\tin\tthe\ttissues\tof\ta\tnormal\thost.\nEven\tthough\tTB\tis\tnot\tas\tcommon\tin\tthe\tUnited\tStates\tas\tin\tsome\tother\tcountries,\tthere\thas\tbeen\ta\nresurgence\tassociated\twith\tHIV\tand\tdrug-resistant\n\tforms\tof\tTB\t(see\t\nChapter\t36\n).\tIn\t2017\tthe\tWHO\nestimated\tapproximately\t10.4\tmillion\tindividuals\tbecame\till\twith\tTB\tand\t1.7\tmillion\tdied.\tAccording | [
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] |
to\tthe\tWHO,\tmultidrug\tresistant\tTB\taccounted\tfor\tapproximately\t600,000\tcases\tof\tTB\tworldwide.\nPathophysiology\nWhen\tan\tinfectious\tTB\tpatient\tcoughs,\tthe\tcough\tdroplets\tcontain\ttuberculous\tbacilli.\tSmall\tparticles\npenetrate\tdeep\tinto\tthe\tlungs.\tEach\n\tof\tthese\ttiny\tdroplets\tmay\tcarry\t1\tto\t5\tbacilli,\twhich\tare\tenough | [
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night\tsweats,\tanorexia,\tand\tweight\tloss.\nMedical\tmanagement\nAn\timportant\tcomponent\tof\tmanagement\tis\tto\tplace\tthese\tpatients\tin\trespiratory\tisolation\tto\tprevent\nspread\tof\tinfection\tuntil\tthe\tsmear\tfor\tsputum\tacid\tfast\tbacillus\t(AFB)\tcomes\tback\tnegative.\tAs\tsoon\nas\tthe\tdiagnosis\tis\testablished,\ttreatment\twith\tfour\tanti-TB\tmedications—INH,\n\trifampin, | [
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rifampin,\npyrazinamide,\tand\tethambutol—is\tstarted.\tEach\tdrug\thas\tfood-nutrient\tinteractions\t(see\t\nAppendix\n13\n).\tThese\tmedications\tare\tcontinued\tfor\t2\tmonths,\tand\tthen\tonly\trifampin\tand\tINH\tare\tcontinued\nfor\tan\tadditional\t4\tmonths.\tDuration\tof\ttreatment\tmay\tbe\tlonger\tin\tsome\tpatients.\nMedical\tnutrition\ttherapy | [
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] |
Medical\tnutrition\ttherapy\nMalnutrition\tis\tcommon\tin\tpatients\twith\tpulmonary\tTB,\tand\tnutritional\tsupplementation\n\tis\tnecessary.\nProtein\tstatus\tcan\tbe\tassessed\tby\tlooking\tat\tblood\tlevels\tof\tacute\tphase\treactants\t(inflammatory\nproteins)\t(see\t\nTable\t5.4\n\tin\t\nChapter\t5\n),\tanthropometric\tindices,\tand\tthe\tmicronutrient\tstatus\tof\tTB\npatients\t( | [
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patients\t(\nMiyata\tet\tal,\t2013\n).\nTB\tleads\tto\tor\tworsens\tany\tpreexisting\tcondition\tof\tmalnutrition\tand\tincreases\tcatabolism.\tThe\nWHO\tguidelines\tsuggest\thospitalization\tof\tpatients\twho\tare\n\tseverely\tundernourished\tdue\tto\nincreased\trisk\tof\tdeath.\tDietary\tsupplementation\tis\trecommended\tuntil\tthe\tpatient\tachieves\ta\tBMI\tof\n18.5\t(\nBhargava\tet\tal,\t2013\n). | [
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18.5\t(\nBhargava\tet\tal,\t2013\n).\nActive\tTB\tis\tassociated\twith\tweight\tloss,\tcachexia,\tand\tlow\tserum\tconcentration\tof\tleptin.\tThere\tis\na\tsynergistic\tinteraction\tbetween\tmalnutrition\tand\tinfection.\tRecurrent\tinfection\tleads\tto\tworsening\nnutritional\tstatus\tand\tloss\tof\tbody\n\tnitrogen.\tThe\tresulting\tmalnutrition,\tin\tturn,\tcreates\ta\thigher | [
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nitrogen.\tThe\tresulting\tmalnutrition,\tin\tturn,\tcreates\ta\thigher\nsusceptibility\tto\tinfection\t(\nMiyata\tet\tal,\t2013\n).\nIn\tthe\tshort\tterm,\tmalnutrition\tincreases\tthe\trisk\tof\tinfection\tand\tearly\tprogression\tof\tinfection\tto\nproduce\tactive\tTB.\tIn\tthe\tlong\tterm,\tmalnutrition\tincreases\tthe\trisk\tof\treactivation\tof\tthe\tTB\tdisease. | [
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Malnutrition\talso\tcan\tlower\tthe\teffectiveness\tof\tthe\tanti-TB\tdrug\tregime,\twhich\n\tpatients\thave\tto\tbe\non\tfor\tseveral\tmonths.\tThe\tefficacy\tof\tBacillus\tCalmette-Guerin\t(BCG)\tvaccine\tcan\talso\tbe\timpaired\nby\tmalnutrition.\nUpon\tcorrection\tof\tnutritional\tdeficiencies,\tmalnutrition-induced\tloss\tof\tcertain\timmune\tprocesses | [
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can\tbe\treversed\trapidly.\tNutritional\tintervention\tin\tcombination\twith\tappropriate\tmedications\tdoes\nimprove\tthe\toutcome\tof\tmalnourished\tTB\tpatients.\nEnergy\nCurrent\n\tenergy\trecommendations\tare\tthose\tfor\tundernourished\tand\tcatabolic\tpatients,\t35\tto\t40\nkcal/kg\tof\tideal\tbody\tweight.\tFor\tpatients\twith\tany\tconcomitant\tinfections\tsuch\tas\tHIV,\tenergy | [
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requirements\tincrease\tby\t20%\tto\t30%\tto\tmaintain\tbody\tweight.\nProtein\nProtein\tis\tvital\tin\tpreventing\tmuscle\twasting,\tand\tan\tintake\tof\t15%\tof\tenergy\tneeds\tor\t1.2\tto\t1.5\tg/kg\nideal\tbody\tweight,\tapproximately\t75\tto\t100\n\tg\tper\tday,\tis\trecommended.\nVitamins\tand\tminerals | [
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0.007919211871922016
] |
g\tper\tday,\tis\trecommended.\nVitamins\tand\tminerals\nPoor\tnutritional\tintake\tassociated\twith\tTB\twill\tlikely\tpromote\tmicronutrient\tdeficiencies\t(\nKant\tet\tal,\n2015\n).\tProviding\tsupplemental\tzinc,\tvitamin\tD,\tvitamin\tE,\tand\tselenium\twill\tprobably\tincrease\tserum\nlevels\tof\tthese\tnutrients\tbut\tthe\tevidence\thas\tnot\tdemonstrated\tsignificant\tclinical\tbenefit\t( | [
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Grobler\net\tal,\t2016\n).\tSupplementing\tthese\tnutrients\n\tabove\tthe\trecommended\tdaily\tamounts\tseems\tto\tbe\nunnecessary\tdue\tto\tthe\tunreliable\tevidence\t(\nGrobler\tet\tal,\t2016\n).\nIsoniazid\tis\tan\tantagonist\tof\tvitamin\tB\n6\n\t(pyridoxine)\tand\tis\tfrequently\tused\tin\tTB\ttreatment.\tIt\tmay | [
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6\n\t(pyridoxine)\tand\tis\tfrequently\tused\tin\tTB\ttreatment.\tIt\tmay\ncause\trare\tinstances\tof\tperipheral\tneuropathy\tresulting\tfrom\tthe\tnutritional\tdepletion\tof\tvitamin\tB\n6\n.\nA\tstandard\tprocedure\tis\tto\tsupplement\tadults\twith\t25\tmg\tof\tvitamin\tB\n6\n\tper\tday\n\tto\tovercome\tthis\ndrug-nutrient\tinteraction.\tVitamin\tB\n6 | [
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6\n\tper\tday\n\tto\tovercome\tthis\ndrug-nutrient\tinteraction.\tVitamin\tB\n6\n\tsupplementation\twill\tbe\tneeded\tfor\texclusively\tbreastfed\ninfants,\tmalnourished\tchildren,\tand\tHIV-infected\tchildren\tand\tadolescents\t(\nRodà\tet\tal,\t2016\n).\nResearch\tindicates\tsome\thealthy\tchildren\tcould\tdevelop\tmild\tsymptom-free\tpyridoxine\tdeficiency\n(\nRodà\tet\tal,\t2016\n). | [
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Studies\thave\tdocumented\tan\tincreased\tprevalence\tof\tanemia\tin\tTB\tpatients,\n\twhich\tis\tassociated\nwith\tincreased\trisk\tof\tdeath.\tTo\tguide\tclinical\tdecision\tmaking\tand\tprovide\ttreatment\nrecommendations,\tfactors\tthat\tcontribute\tto\tthe\tTB-associated\tanemia\thave\tto\tbe\tdetermined. | [
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Although\tother\tcauses\tdo\tcoexist,\tiron\tdeficiency\tanemia\tis\tthe\tmost\timportant\tcontributor\tin\tthe\ndevelopment\tof\tanemia\tin\tTB\tpatients\t(\nIsanaka\tet\tal,\t2012\n).\nIron\tis\tan\tessential\tmicronutrient\tnot\n\tonly\tfor\thumans\tbut\talso\tfor\tbacteria\tsuch\tas\t\nM.\ttuberculosis\n;\nTB\tis\tdependent\ton\tthe\thost’s\tiron\tsupply\t(\nCarver,\t2018 | [
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;\nTB\tis\tdependent\ton\tthe\thost’s\tiron\tsupply\t(\nCarver,\t2018\n).\tProviding\tiron\teither\tas\ta\tsupplement\tor\nblood\ttransfusion\tcould\tincrease\trisk\tof\tinfection\tbut\tat\tthis\ttime\tthis\tis\tcontroversial\t(\nCarver,\t2018\n).\nThe\tuse\tof\tiron\ttherapy\tis\tnot\tuniversally\trecommended.\tHowever,\tif\tiron\tstudies\tshow\tiron\ndeficiency,\tiron\ttherapy\tis\tthen\tinitiated | [
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deficiency,\tiron\ttherapy\tis\tthen\tinitiated\n\t(see\t\nChapter\t31\n\tfor\tmanagement\tof\tiron\tdeficiency\tanemia).\nLung\tcancer\nLung\tcancer\tremains\tthe\tleading\tcause\tof\tcancer\tdeaths\tfor\tmales\tand\tfemales\tin\tthe\tUnited\tStates.\nIn\t2012\t1.8\tmillion\tpatients\tworldwide\twere\tdiagnosed\twith\tlung\tcancer\t(\nMannino,\t2014\n). | [
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Mannino,\t2014\n).\nNeoplasms\tof\tthe\tlower\trespiratory\ttract\tare\ta\theterogeneous\tgroup\tof\ttumors.\tThe\tgroup\ncommonly\tcalled\t\nbronchogenic\tcarcinomas\n\tcomprises\n\tsquamous\tcell\tcarcinoma,\tadenocarcinoma,\nsmall\tcell\tundifferentiated\tcarcinoma,\tand\tlarge\tcell\tundifferentiated\tcarcinoma\tand\taccount\tfor\t90% | [
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of\tall\tthe\tneoplasms\tof\tthe\tlower\trespiratory\ttract.\tMortality\tis\tmore\tcommon\tin\tmales\tthan\tfemales,\nalthough\tthis\tdifference\tis\tdiminishing.\tWhile\tthe\tfemale\tincidence\trate\tis\tstabilizing,\tthe\tmale\nincidence\trate\tseems\tto\tbe\tdecreasing\t(\nBaldini,\t2014\n).\nPathophysiology | [
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Baldini,\t2014\n).\nPathophysiology\nOften\tlung\tcancer\tis\tdetected\ton\ta\troutine\tchest\tradiograph\tin\tan\tasymptomatic\tsmoker.\tOther\npatients\tmay\tpresent\twith\tsymptoms\trelated\tto\tthe\ttumor\titself,\tsymptoms\trelated\tto\tthe\tlocal\nextension\tof\tthe\ttumor\tor\twidespread\tmetastases,\tor\tsystemic\tsymptoms\tsuch\tas\tanorexia,\tweight | [
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loss,\tweakness,\tand\tparaneoplastic\tsyndromes.\nDyspnea\tis\tthe\tmost\tburdensome\tcancer\tsymptom\tand\toccurs\n\tin\t25%\tto\t40%\tof\tlung\tcancer\npatients\tat\tdiagnosis.\tIn\taddition\tto\tthe\ttumor,\tother\tfactors\tcontribute\tto\tthe\tsymptom\tof\tdyspnea—\nfactors\tsuch\tas\tpericardial\teffusion,\tanemia,\tfatigue,\tdepression,\tanxiety,\tmetastatic\tinvolvement\tof | [
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other\torgans,\taspiration,\tanorexia-cachexia\tsyndrome,\tand\tpleural\teffusion.\nPatients\twith\tlung\tcancer\tsuffer\tfrom\tprogressive\tweight\tloss\twith\tchanges\tin\tbody\tcomposition.\nMalnutrition\timpairs\tthe\tcontractility\tof\tthe\trespiratory\tmuscles,\taffecting\tendurance\tand\trespiratory\nmechanics. | [
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mechanics.\nCough\tis\tpresent\tin\t50%\tto\t75%\tof\tlung\tcancer\tpatients\tat\tpresentation\tand\toccurs\tmost\tfrequently\nin\tsquamous\tcell\tand\tsmall\tcell\tcarcinoma\tbecause\tof\ttheir\ttendency\tto\tinvolve\tcentral\tairways\n(\nKocher\tet\tal,\t2015\n).\nPain\tand\tfatigue\tare\tcommon\tsymptoms\tassociated\twith\tlung\tcancer.\n\tThe\ttumor\tmay\tproduce | [
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stage\tcancer\tand\t75%\tto\t100%\tof\tadvanced\tstage\tcancer\tpatients\treport\tfatigue\t(\nKocher\tet\tal,\t2015\n).\nPulmonary\tcachexia\tsyndrome\taffects\tpatients\twith\tadvanced\tlung\tdisease.\tIn\tlung\tcancer,\tweight\nloss\tis\tassociated\twith\tincreasing\tmortality,\tand\tweight\tloss\tof\teven\t5%\tindicates\ta\tpoor\tprognosis. | [
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Although\tanorexia\tand\tcachexia\tare\ttwo\tdifferent\tentities,\tthey\toften\tare\tused\tinterchangeably\n(\nKocher\tet\tal,\t2015\n)\t(see\t\nChapter\t35\n).\nMedical\tmanagement\nThe\tchoice\tof\tdefinitive\tmanagement\tfor\n\ta\tparticular\tpatient\tis\tdetermined\tby\tnumerous\tfactors, | [
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a\tparticular\tpatient\tis\tdetermined\tby\tnumerous\tfactors,\nsuch\tas\tthe\ttumor\tcell\ttype,\ttumor\tstage,\tresectability\tof\tthe\ttumor,\tand\tsuitability\tof\tthe\tpatient\tfor\ngeneral\tanesthesia\tand\tsurgery.\tSome\tpatients\tneed\tgeneral\tpalliative\tcare\tin\tterms\tof\tpsychological | [
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1.\t\nTreat\tthe\treversible\tcauses\tof\tanorexia\tsuch\tas\tearly\tsatiety\n2.\t\nEvaluate\tthe\trate\tand\tseverity\tof\tweight\tloss\n3.\t\nTreat\tthe\tsymptoms\tinterfering\twith\tfood\tintake:\tnausea\tand\n\tvomiting,\tdyspnea,\tmucositis,\nconstipation,\tand\tpain\n4.\t\nAssess\tthe\tuse\tof\tappetite\tstimulants\tlike\tmegestrol\tacetate\tand\tDecadron\t(corticosteroids)\n5. | [
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5.\t\nProvide\tnutritional\tsupport\t(enteral\tor\tparenteral)\t(\nDel\tFerraro\tet\tal,\t2012\n)\nCancer\tcachexia\tsyndrome\t(CCS)\n\tis\tthe\tpresence\tof\ta\tmetabolic\tstate\tthat\tleads\tto\tenergy\tand\nmuscle\tstore\tdepletion\tin\tlung\tcancer\tpatients.\tWhen\tpatients\texperience\n\tCCS,\tthey\tlose\tadipose\tand | [
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] |
CCS,\tthey\tlose\tadipose\tand\nskeletal\tmuscle\tmass.\tChanges\tin\thormone\tand\tcytokine\tlevels,\talong\twith\ttumor\tbyproducts,\tcause\nCCS.\tWeight\tloss\tseen\twith\tCCS,\tunlike\tstarvation,\tis\tirreversible\tand\tcontinues\tto\tworsen\tdespite\nincreased\tnutritional\tintake\t(\nHuhmann\tand\tCamporeale,\t2012\n)\t(see\t\nChapter\t35\n). | [
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] |
Huhmann\tand\tCamporeale,\t2012\n)\t(see\t\nChapter\t35\n).\nHowever,\tdespite\tthese\tfindings,\treversible\tcauses\tof\tanorexia\tshould\tbe\tsought\tand\ttreated.\nAlthough\n\tnutritional\tsupport\tdoes\tnot\timprove\tspirometric\tvalues\tand\tarterial\tblood\tgas\tand\tdoes\tnot\nstop\tweight\tloss,\tit\tdoes\tmodestly\timprove\tclinical\toutcomes\tsuch\tas\tthe\t6-minute\twalk\ttest,\tquality | [
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1.\t\nSmall\tfrequent\tmeals\tthat\tare\tcalorie\tand\tprotein\tdense\n2.\t\nProvide\tcalorie\tlevel\tthat\tmeets\tor\texceeds\tthe\tresting\tenergy\texpenditure\t(REE)\n3.\t\nRest\tbefore\tmeals\n4.\t\nMeals\tthat\trequire\tminimal\tpreparation\n5.\t\nOral\tnutritional\tsupplements\t(homemade\tor\tpreprepared) | [
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5.\t\nOral\tnutritional\tsupplements\t(homemade\tor\tpreprepared)\nWith\tpulmonary\tCCS,\tpatients\tare\tunable\tto\tgain\tweight\twith\tnutritional\tinterventions\talone.\nProkinetic\n\tagents\tfor\tdelayed\tgastric\temptying\tcan\tbe\tused\twith\tcareful\tconsideration\tof\tside\teffects. | [
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that\trepeated\tintravenous\n\t(IV)\tadministration\tof\tghrelin\timproves\tbody\tcomposition,\tlowers\tmuscle\nwasting,\tand\tincreases\tfunctional\tcapacity\t(\nBellini,\t2013\n).\nOne\tstudy\tsuggests\tthat\twhole\tbody\tprotein\tmetabolism\tin\tpulmonary\tpatients\tmay\tbenefit\tfrom | [
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branched-chain\tamino\tacid\t(BCAA)\tsupplementation.\tThis\tstudy\twas\tthe\tfirst\tof\tits\tkind\tin\tassessing\nthe\tclinical\tbenefits\tof\tsupplementing\tBCAA\tin\ta\tpreoperative\tpulmonary\n\trehabilitation\tcenter;\t6.2\tg\nof\tBCAA\tsupplementation\twas\tthe\trecommended\tdaily\tdosage.\tHowever\tthe\teffect\tof\tBCAA | [
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supplementation\tfor\tlung\tcancer\tpatients\thas\tnot\tbeen\tclarified\tand\trequires\tfurther\tstudy\tbefore\nspecific\trecommendations\tcan\tbe\tmade.\tA\tcomprehensive\tpulmonary\trehabilitation\tprotocol\tincludes\nnutritional\tsupport\tand\tphysical\texercise\t(\nHarada\tet\tal,\t2013\n).\nObesity\thypoventilation\n\tsyndrome\nObesity\thypoventilation\tsyndrome\t(OHS) | [
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syndrome\nObesity\thypoventilation\tsyndrome\t(OHS)\n\tis\tdefined\tas\ta\tBMI\tof\tmore\tthan\t30\tkg/m\n2\n\tand\talveolar\nhypoventilation\tdefined\tby\tarterial\tCO\n2\n\t(Paco\n2\n)\tlevel\tof\tmore\tthan\t45\tmm\tHg\tduring\twakefulness,\nwhich\toccurs\tin\tthe\tabsence\tof\tother\tconditions\tthat\tcause\thypoventilation\t(\nPiper\tand\tGrunstein,\n2011\n). | [
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Piper\tand\tGrunstein,\n2011\n).\nAlveolar\thypoventilation\tin\tOHS\tis\trelated\tto\tthe\tmultiple\tphysiologic\tabnormalities\tassociated\n\twith\nobesity:\tobstructive\tsleep\tapnea\t(OSA),\tincreased\twork\tof\tbreathing,\trespiratory\tmuscle\timpairment,\na\tdepressed\tcentral\tventilator\tdrive,\tand\treduced\teffects\tof\tneurohumoral\tmodulators\t(e.g.,\tleptin)\n(\nKoenig,\t2011\n; | [
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(\nKoenig,\t2011\n;\t\nPiper\tand\tGrunstein,\t2011\n).\nObstructive\tsleep\tapnea\t(OSA)\n\tis\ta\tcommon\tchronic\tdisorder,\twhich\tis\tcharacterized\tby\tloud\nsnoring,\texcessive\tdaytime\tsleepiness,\tand\twitnessed\tbreathing\n\tinterruptions\tor\tawakenings\tbecause\nof\tgasping\tor\tchoking.\tThe\tpresence\tor\tabsence\tof\tOSA\tand\tits\tseverity\tusually\tis\tconfirmed\tby\ta | [
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sleep\tstudy\t(polysomnography)\tbefore\tinitiating\ttreatment\t(\nKapur\tet\tal,\t2017\n).\tThe\tpolysomnography\nalso\tserves\tas\ta\tbaseline\tto\testablish\tthe\teffectiveness\tof\tthe\tsubsequent\ttreatment\t(\nEpstein\tet\tal,\n2009\n).\nMedical\tmanagement\nDepending\ton\tthe\tnumber\tof\tepisodes\n\tof\tapnea\tor\t\nhypopnea\n\t(overly\tshallow\tbreathing)\tper\thour, | [
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modalities\tfor\tOSA\tmust\tbe\tused\tin\taddition\tto\tweight\tloss\n\tbecause\tof\tthe\tlow\tsuccess\tand\tlow\tcure\nrates\tby\tdietary\tapproach\talone.\nMedical\tnutrition\ttherapy\nWeight\treduction\tby\tMNT\tor\tby\tbariatric\tsurgery\tremains\tan\timportant\tcomponent\tof\tmanagement\nof\tthese\tcases\t(see\t\nChapter\t20\n).\tA\tguideline\tfrom\tthe\tAmerican\tThoracic\tSociety\trecommends\ta | [
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Hudgel\tet\tal,\t2018\n).\tIn\ta\tmulticenter\nstudy\tof\tpatients\twith\tOSA\tundergoing\tRoux-en-Y\tgastric\tbypass\tsurgery,\tOSA\twas\treduced\tfrom\t71%\nto\t44%\tone\tyear\tlater\tin\tthese\tpatients;\thowever,\tmoderate\tto\tsevere\tOSA\tremained\tin\t20%\tof\tthe\npatients\t(\nPeromaa-Haavisto\tet\tal,\t2017\n).\nPleural\teffusion\nPleural\teffusion | [
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that\tcontains\tabout\t10\tto\t20\tmL\tfluid.\tIf\tthere\tis\tincreased\tproduction\tor\tdecreased\tdrainage\tin\tthe\npleural\tspace,\tfluid\tcan\taccumulate.\tPleural\teffusion\tcan\tbe\teither\n\ttransudate\tor\texudate\t(\nFeller-\nKopman\tand\tLight,\t2018\n).\tTransudate\teffusion\tis\tusually\tdue\tto\tcongestive\theart\tfailure,\tliver | [
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disease,\tor\tkidney\tdisease,\twhile\texudate\teffusion\tmay\toccur\tdue\tto\tinfection,\tmalignancy,\tand\nautoimmune\tdisorders.\nPleural\teffusion\tcan\tbe\tfound\tincidentally\ton\tchest\timaging\tin\tpatients\twho\tare\tasymptomatic\tor\ncan\tpresent\twith\tshortness\tof\tbreath,\tchest\tpain,\tor\tsymptoms\n\trelated\tto\tthe\tunderlying\tcause\tsuch | [
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as\tpneumonia\tor\tcongestive\theart\tfailure.\tEffusions\tcan\tbe\tunilateral\tor\tbilateral.\t\nFig.\t33.9\n\tis\ta\tCT\nscan\tof\ta\tpatient\twith\tbilateral\tpleural\teffusion.\nFIG.\t33.9\nComputed\ttomography\t(CT)\tscan\tshowing\tbilateral\tpleural\teffusions.\nMedical\tmanagement\nThe\tmanagement\tof\tpleural\teffusion\tdepends\ton\tnumerous\tfactors\tand\tusually\tinvolves\tdrainage\tof | [
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heart\tfailure.\tMalnutrition\tmay\texist\tdue\tto\tthe\tprimary\tdisorder\tand\tshould\tbe\tappropriately\ndiagnosed\tand\ttreated.\nChylothorax\nChylothorax\n\tis\ta\trare\tcause\tof\tpleural\teffusion.\tIt\tis\tcaused\tby\tthe\tdisruption\tor\tobstruction\tof\tthe\nthoracic\tduct,\twhich\tresults\tin\tthe\tleakage\tof\tchyle\t(lymphatic\tfluid\tof\tintestinal\torigin)\tinto\tthe | [
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pleural\tspace.\tThe\tfluid\ttypically\thas\ta\tmilky\tappearance.\tA\tpleural\tfluid\ttriglyceride\tconcentration\tof\nmore\tthan\t110\tmg/dL\tstrongly\tsupports\tthe\tdiagnosis\n\tof\ta\tchylothorax\t(\nHeffner,\t2018\n).\nChylothorax\tcan\tresult\tfrom\tnontraumatic\tcauses\tsuch\tas\tsarcoidosis\tor\tbenign\tidiopathic | [
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chylothorax.\tIt\tcan\toccur\tbecause\tof\tsurgical\ttrauma\tsuch\tas\tpostoperative\tchylothorax\tor\npostpneumonectomy\tchylothorax.\nMedical\tmanagement\nThe\tprinciples\tof\tmanagement\tof\tchylothorax\tare\t(1)\ttreatment\tof\tthe\tunderlying\tcondition\tsuch\tas\nsarcoidosis,\tinfection,\tlymphoma,\n\tor\tmetastatic\tcarcinoma\tand\t(2)\tpleural\tdrainage\tto\trelieve | [
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(MCTs)\tcould\tbe\tadded\tto\tthe\tdiet\tor\tenteral\tformula\tbecause\tMCTs,\tafter\tabsorption\tin\tthe\ngastrointestinal\ttract,\tbypass\tthe\tlymphatic\tsystem\tand\tare\tdirectly\ttransported\tto\tthe\tliver\tvia\tthe\nportal\tvein.\tMCTs\tare\tnot\tvery\tpalatable\tand\tthey\thave\n\tside\teffects\tsuch\tas\tgastrointestinal\tupset, | [
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side\teffects\tsuch\tas\tgastrointestinal\tupset,\nsteatorrhea,\tand\thyperlipidemia.\tAs\tthe\tchylous\tdrainage\tdeclines,\tfat\tintake\tcan\tbe\tgradually\nincreased.\tIt\tmay\ttake\t7\tto\t10\tdays\tfor\tthe\tchylous\tdrainage\tto\tclear.\tPatients\twith\thigh\tvolume\nchylous\tdrainage\t(greater\tthan\tone\tliter)\twill\tlikely\tneed\tsurgery\tfor\tcorrection.\tParenteral\tnutrition | [
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When\tan\tinjury\tproduces\tdiffuse\talveolar\tdamage,\tproinflammatory\tcytokines\tare\treleased.\tThese\ncytokines\tpromote\tmigration\tof\tneutrophils\tto\tthe\tlungs,\twhere\tthey\tbecome\tactivated\tand\trelease\ntoxic\n\tmediators,\twhich\tproduce\tfurther\tdamage\tto\tthe\talveolar\tepithelium\tand\tcapillary\tendothelium. | [
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] |
This\tdamage\tallows\tprotein\tto\tescape\tinto\tthe\tinterstitium.\tAlveoli\tget\tfilled\twith\tbloody,\nproteinaceous\tfluid\twhich\tinterferes\twith\tgas\texchange,\tand\tsevere,\trefractory\thypoxemia\tresults.\nVarious\tclinical\tconditions\tcan\tlead\tto\tthe\tdevelopment\tof\tARDS\t(\nTable\t33.3\n).\nTABLE\t33.3\nCommon\tClinical\tConditions | [
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] |
Table\t33.3\n).\nTABLE\t33.3\nCommon\tClinical\tConditions\n\tAssociated\twith\tAcute\tRespiratory\tDistress\tSyndrome\t(ARDS)\nMost\tCommon\nLess\tCommon\nPneumonia\nSepsis\nDrug\ttoxicity\nAspiration\nInhalation\tinjury\nNear\tdrowning\nRespiratory\tsyncytial\tvirus\nTransfusion\trelated\tacute\tlung\tinjury\nTrauma | [
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Transfusion\trelated\tacute\tlung\tinjury\nTrauma\nAdapted\tfrom\tSaguil\tA,\tFargo\tM:\tAcute\trespiratory\tdistress\tsyndrome:\tdiagnosis\tand\tmanagement,\t\nAm\tFam\tPhys\n\t85:352,\t2012.\nPatients\twith\tARDS\tpresent\n\twith\tacute\tonset\tof\tshortness\tof\tbreath,\ttachypnea,\tand\thypoxemia,\nwhich\tis\trefractory\tto\toxygen\tsupplementation.\nMedical\tmanagement | [
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which\tis\trefractory\tto\toxygen\tsupplementation.\nMedical\tmanagement\nThe\tprinciples\tof\tARDS\tmanagement\tare\tthe\tfollowing\t(\nSiegel,\t2013\n):\n•\t\nTreatment\tof\tunderlying\tcause\tsuch\tas\tsepsis,\taspiration,\tor\tbacterial\tpneumonia\n•\t\nMechanical\tventilatory\tsupport\n•\t\nICU\tincluding\tsedation\twith\tor\twithout\tparalytic\tdrug\n•\t\nEnsuring\themodynamic\n\tstability\n• | [
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•\t\nEnsuring\themodynamic\n\tstability\n•\t\nPrevention\tof\tcomplications\tsuch\tas\tstress\tulcers\t(gastrointestinal\tprophylaxis),\nhyperglycemia,\tdeep\tvenous\tthrombosis,\tand\taspiration\tpneumonia\n•\t\nNutritional\tsupport\n•\t\nTherapies\twith\tcorticosteroids,\texogenous\tsurfactant,\tantioxidants,\tand\tinhaled\tnitric\toxide | [
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have\tbeen\tused\tbut\thave\tnot\tshown\tconsistent\tbenefit.\nMedical\tnutrition\ttherapy\nMalnutrition\tis\tcommon\tin\tthese\n\tpatients\twho\trequire\tmechanical\tventilation.\tPatients\twith\tsevere\nrespiratory\tdisease\thave\tincreased\tmetabolic\tneeds\tand\trequire\tprompt\tinitiation\tof\tsupplemental | [
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nutrition.\tIt\tis\timportant\tto\tconsider\tissues\trelated\tto\tenergy\tand\tprotein\tuse.\nNutrition\tsupport\tin\tARDS\tpatients\tis\tnecessary\tfor\tpreventing\tcumulative\tcaloric\tdeficits,\tloss\tof\nLBM,\tmalnutrition,\tand\tdeterioration\tof\trespiratory\n\tmuscle\tstrength\t(\nKrzak\tet\tal,\t2011\n).\tAccording\tto | [
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muscle\tstrength\t(\nKrzak\tet\tal,\t2011\n).\tAccording\tto\nthe\t2016\tSociety\tof\tCritical\tCare\tMedicine\tand\tAmerican\tSociety\tfor\tParenteral\tand\tEnteral\nNutrition\t(SCCM/ASPEN)\tguidelines,\ta\tstandard\tenteral\tformula\tcan\tbe\tadministered\tand\ta\nconcentrated\tformula\tmay\tbe\tneeded\tfor\tthose\twho\tare\tfluid-overloaded\tor\thave\tpulmonary\tedema\n(\nMcClave\tet\tal,\t2016 | [
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] |
(\nMcClave\tet\tal,\t2016\n).\nPatients\twith\tARDS\tare\tat\thigh\trisk\tfor\tcomplications\n\tas\ta\tresult\tof\tunderfeeding\tor\toverfeeding\n(\nTable\t33.4\n).\tReduction\tin\trespiratory\tmuscle\tstrength\tis\ta\tnegative\tconsequence\tof\tunderfeeding,\nwhich\tleads\tto\tproblems\tin\tweaning\tfrom\tmechanical\tventilation.\tIn\taddition,\tpoor\twound\thealing, | [
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] |
hyperglycemia,\tdelayed\tweaning\tfrom\tmechanical\tventilation,\tand\tdelayed\twound\thealing\t(\nKrzak\tet\nal,\t2011\n).\tEffective\tMNT\trequires\tcareful\tassessment\tand\tmonitoring.\tSee\t\nChapter\t37\n\tfor\tfurther\ndiscussion\ton\tMNT\tfor\tmetabolically\tstressed\tpatients.\nTABLE\t33.4 | [
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] |
discussion\ton\tMNT\tfor\tmetabolically\tstressed\tpatients.\nTABLE\t33.4\nComplications\tResulting\tfrom\tOverfeeding\tand\tUnderfeeding\tin\tAcute\tRespiratory\tDistress\tSyndrome\n(ARDS)\tPatients\nOverfeeding\nUnderfeeding\nNosocomial\tinfections\nHypercapnia\nImmunosuppression\nFailure\tin\tweaning\tfrom\tmechanical\tventilator\nPoor\twound\thealing\nElectrolyte\timbalance | [
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Poor\twound\thealing\nElectrolyte\timbalance\nAzotemia\nNosocomial\tinfections\nImmunosuppression\nDepressed\trespiratory\tmuscle\tstrength\nFailure\tin\tweaning\tfrom\tmechanical\tventilator\nLow\tventilatory\tdrive\nAdapted\tfrom\tKrzak\tA,\tet\tal:\tNutrition\ttherapy\tfor\tALI\n\tand\tARDS,\t\nCrit\tCare\tClin\n\t27:647,\t2011.\nPneumonia | [
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and\tARDS,\t\nCrit\tCare\tClin\n\t27:647,\t2011.\nPneumonia\nAn\tinflammatory\tcondition\tof\tthe\tlungs\tthat\tcauses\tchest\tpain,\tfever,\tcough,\tand\tdyspnea\tis\tcalled\npneumonia\n.\tIn\tthe\tclinical\tsetting\tthere\tare\tvarious\tkinds\tof\tpneumonias,\tsuch\tas\tcommunity-\nacquired\tpneumonia,\twhich\tmay\tbe\tviral\tor\tbacterial;\thospital-acquired\tpneumonia;\tpneumonia\tin\tan | [
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immune\tcompromised\thost;\tventilator-associated\tpneumonia\n\t(VAP);\tand\taspiration\tpneumonia,\twhich\nwill\tbe\tdiscussed\there.\tAspiration\tis\ta\tcommon\tevent\teven\tin\thealthy\tadults\tand\tusually\tcauses\tno\ndeleterious\teffects.\tAt\tleast\tone\thalf\tof\thealthy\tadults\taspirate\tduring\tsleep.\tHowever,\twhen\tthis\naspirate\tresults\tin\tpulmonary\tinfection,\tit\tresults\tin | [
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aspirate\tresults\tin\tpulmonary\tinfection,\tit\tresults\tin\t\naspiration\tpneumonia\n\t(\nBox\t33.3\n).\nBOX\t33.3\nConditions\tThat\tPredispose\ta\tPatient\tto\tAspiration\tPneumonia\n•\t\nImpaired\tlevel\tof\tconsciousness,\twith\tcompromised\tclosure\tof\tglottis\tand\timpaired\tcough\nreflex\n•\t\nDysphagia\tfrom\tneurologic\tconditions\t(i.e.,\tstroke)\n• | [
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reflex\n•\t\nDysphagia\tfrom\tneurologic\tconditions\t(i.e.,\tstroke)\n•\t\nGastric\treflux,\tdisorders\tof\tor\tsurgery\ton\tthe\tupper\tgastrointestinal\ttract\n•\t\nMechanical\tdisruption\tof\tthe\tglottis\tclosure\tbecause\tof\tendotracheal\ttube,\ttracheostomy,\nbronchoscopy,\tand\tinterference\twith\tthe\tcardiac\tsphincter\tby\tgastroduodenal\n\tendoscopy\tor | [
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UpToDate\n,\tWaltham,\nMass,\t2012.\tRetrieved\tfrom\t\nhttp://www.uptodate.com/contents/aspiration-pneumonia-in-adults\n.\nPathophysiology\nTwo\tconditions\tmust\texist\tfor\taspiration\tpneumonia\tto\tdevelop.\tFirst,\tthere\tis\ta\tbreach\tin\tthe\tnormal\ndefense\tmechanisms,\tsuch\tas\tfailure\tof\tglottis\tclosure\tor\timpaired\tcough\treflex,\tand\tsecond,\ta\tlarge | [
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enough\tinoculum\tenters\tthe\tlungs.\tThe\taspirate\tcontains\tgastric\tacid,\twhich\thas\ta\tdirect\ttoxic\teffect\non\tthe\tlungs,\tparticulate\tmatter\tthat\tmay\tcause\tairway\tobstruction\tand\tatelectasis,\n\tand\toral\tbacteria,\nwhich\tcan\tresult\tin\tinfection\tand\tpneumonia.\tPathogens\tsuch\tas\t\nS.\tpneumonia\n,\t\nHaemophilus\ninfluenzae\n,\tgram-negative\tbacilli,\tand\t\nS.\taureus | [
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,\t\nHaemophilus\ninfluenzae\n,\tgram-negative\tbacilli,\tand\t\nS.\taureus\n\tare\tvirulent,\tand\tonly\ta\tsmall\tinoculum\tis\tneeded\tto\ncause\tpneumonia.\tBy\tconvention,\taspiration\tpneumonia\tis\tcaused\tby\tless-virulent\torganisms\tsuch\tas\nanaerobes,\twhich\tare\tpart\tof\tthe\tnormal\toral\tflora,\twith\tpredisposing\tsituations.\nMedical\n\tmanagement | [
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tracheal\tsuction.\tHowever,\tthis\tmaneuver\twill\tnot\tnecessarily\tprotect\tthe\tlungs\tfrom\tchemical\tinjury,\nwhich\toccurs\tinstantly\t(\nBartlett,\t2012\n).\tThe\tmain\ttreatment\tin\tthis\tsituation\n\tis\tantibiotics\tand\tto\nsupport\tthe\tpulmonary\tfunction.\tUse\tof\tglucocorticoids\tin\tchemical\tpneumonitis\tis\tcontroversial\tand\nnot\tusually\trecommended. | [
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not\tusually\trecommended.\nAspiration\tpneumonia\tusually\tpresents\twith\tindolent\tsymptoms.\tMany\tpatients\tpresent\twith\ncomplications\tsuch\tas\tlung\tabscess,\temphysema,\tand\tnecrotizing\tpneumonia.\tOnce\ta\tpatient\thas | [
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