Chronic Obstructive Pulmonary DiseaseManual of Clinical Nutrition Management III- 17 Copyright © 2013 Compass Group, Inc.
nail beds (2). Another physical sign of COPD, cyanosis, is a blue coloration of the skin and mucous membranes
caused by the presence of deoxygenated hemoglobin in blood vessels near the skin surface (2). An assessment
of muscle mass (eg, arm circumference) and an evaluation of signs of muscle wasting or atrophy should be
performed. Patients who take steroids may have decreased respiratory strength, decreased bone mineral
density, increase fracture risk, and hyperglycemia (2). A detailed food and nutrition history focusing on total
energy and carbohydrate intake; intake of omega-3 fatty acids, calcium, and vitamin D; and use of medical
food or other supplements is relevant in the COPD patient population (2,9). Refer to Morrison Nutrition
Practice Guideline – Chronic Obstructive Pulmonary Disease for a review of common associated nutrition
diagnoses in the acute care setting (10).
Nutrition Intervention
The primary goals of medical nutrition therapy in the management of COPD are to preserve lean body mass,
prevent involuntary weight loss, and maintain nutritional status (2,9). Nutrition intervention strategies should
be determined based on the patient’s nutrition diagnosis, primary medical diagnosis, coexisting diseases,
level of care, and risk factors identified during the comprehensive nutrition assessment. Refer to the
Morrison Nutrition Practice Guideline – Chronic Obstructive Pulmonary Disease (10) for detailed nutrition
assessment and nutrition intervention strategies for the acute care setting. Nutritional supplementation with
medical food supplements increases the energy intake and promotes the weight maintenance of hospitalized
patients with malnutrition or compromised nutritional status (Grade II) (9). In the ambulatory care setting,
nutritional supplementation may result in increased energy intake, with weight gain more likely when
combined with exercise (Grade II) (9). The ideal macronutrient composition of medical food supplements to
support lung function has not been validated (9); therefore, the selection of supplements should be based on
the patient’s taste preference and the adequacy to meet individualized nutritional needs (2,9).
Acute respiratory distress syndrome is a secondary complication of COPD that requires hospitalization (2,8).
Mechanical ventilation is the primary management, with the objective to keep the lungs at high volume and
prevent airway closure (2). Acute respiratory failure or distress syndrome occurs frequently in patients
undergoing complicated surgery or as a result of trauma, septic shock, or multiorgan failure (2). Early
nutrition intervention and access for enteral feeding support are recommended to prevent further
deterioration of the nutritional status of patients who receive mechanical ventilation. Depending on the
functional status of the gastrointestinal tract, parenteral nutrition may be indicated. (Refer to “Enteral
Nutrition Support for Adults” and “Parenteral Nutrition Support for Adults” in Section IB.)
Energy expenditure: The total daily energy needs of people with COPD are highly variable due to differences
in resting energy expenditure and physical activity levels (Grade III) (9). Inflammation present during stable or
exacerbated COPD increases the resting energy expenditure (Grade III) (9). One small study of ten patients with
severe COPD demonstrated that the measured energy expenditure was 50% higher than the World Health
Organization predictive equation and that the total daily expenditure was widely variable, ranging from 26 to
48 kcal/kg (11). The Academy of Nutrition and Dietetics performed a comprehensive review of the literature
and concluded that further research on the influences of the thermic effect of food, breathing efficiency, and
medications on the energy needs of COPD patients is needed (9). Indirect calorimetry is the best available
method for assessing energy expenditure and establishing energy requirements in COPD patients (2,9). If
indirect calorimetry cannot be performed, energy requirements should be estimated by predictive equations
based on the level of care (2). The energy requirements of most adult COPD patients range from 25 to 35
kcal/kg, depending on weight, coexisting disease processes, and nutritional deficits (2). Patients who are
clinically overfed develop hypercapnia due to increased carbon dioxide production. Hypercapnia increases
the demands of ventilation, which worsens the respiratory status, delays weaning from mechanical
ventilation, or both. Overfeeding, defined as energy intake in excess of metabolic demands, should be avoided
(2). Weight loss is recommended for overweight patients with COPD. In these patients, weight loss improves
respiratory muscle function and decreases shortness of breath (2).
Protein: Provide enough protein to maintain visceral protein status and meet the demands of metabolic
stress. Protein requirements do not increase with COPD (2). Protein increases minute ventilation, oxygen
consumption, and ventilatory response to hypoxia and hypercapnia. In patients with Acute Respiratory
Distress Syndrome, high levels of protein may cause further fatigue, and protein requirements may need to be
temporarily reduced (6).
Carbohydrate and fat: It has been proposed that patients with COPD might benefit from a high-fat,
moderate-carbohydrate diet (eg, 40% to 55% carbohydrate, 30% to 40% fat, and 15% to 20% protein) (12).
The rationale is that carbohydrate as a fuel substrate increases the respiratory quotient. This quotient