Nutritional Status of Patients With Chronic Obstructive Pulmonary Disease and Acute Respiratory Failure

doi:10.1378/chest.103.5.1362

Chest

Volume 103, Issue 5, May 1993, Pages 1362-1368

https://doi.org/10.1378/chest.103.5.1362 Get rights and content

The prevalence and features of malnutrition in COPD patients have been studied extensively in stable conditions but are poorly defined in the presence of acute respiratory failure (ARF). Nutritional status was prospectively assessed, on hospital admission, in 50 consecutive COPD patients presenting with ARF, 27 of them requiring mechanical ventilation (MV). Malnutrition, defined on a multiparameter nutritional index, was observed in 60 percent (30/50) of all patients, and in 39 percent (13/33) of those whose body weight was equal to or above 90 percent ideal body weight (IBW). Malnutrition was more frequent in those patients who required MV than in those who did not (74 percent vs 43 percent, p<0.05). Subcutaneous fat stores were decreased (triceps skinfold thickness [TSF] <80 percent pred) in 68 percent of patients, and markedly depleted (TSF <60 percent pred) in 52 percent of them. The indices of lean body mass, ie, mid-arm muscle circumference (MAMC) and creatinine height index (CHI) were decreased in, respectively, 42 percent and 71 percent of patients, but MAMC was severely depressed (<60 percent pred) in only 6 percent of them. A severe decrease of prealbumin (<100 mg/L), retinol-binding-protein (<20 mg/L), and albumin (<20 g/L) serum concentrations was observed in, respectively, 22 percent, 28 percent, and 4 percent of patients. These results suggest that an assessment of nutritional status using a multiparameter approach should be systematically performed in COPD patients with ARF, especially in those requiring MV, as malnutrition may have deleterious effects on weaning off MV.

Section snippets

Patients

We included 50 COPD patients, consecutively admitted to our department with ARF, and free of any associated condition known to negatively affect nutritional status (cancer, liver disease, chronic renal failure, surgery performed within 6 months, and long-term corticosteroid use with a daily dosage of prednisone superior to 10 mg).

The diagnosis of COPD was made on clinical and radiologic criteria.¹⁰ In the 39 patients who survived that episode of ARF, pulmonary function tests (PFT) were

Nutritional Assessment of the Total Population

All nutritional measurements were performed as scheduled except for two patients in whom Alb, Tf, and CHI were missing for technical reasons.

The mean values of the anthropometric, biochemical, and immunologic NIs, and of the multiparameter NI for the whole study group, are summarized in Table 3.

The percentages of patients with impairment of any given nutritional parameter are presented in Table 4. Body weight was less than 90 percent IBW in 34 percent of patients. A decrease in subcutaneous fat

DISCUSSION

This study shows that COPD patients presenting with an ARF are frequently malnourished. Malnutrition defined by a multiparameter NI was observed on hospital admission in 60 percent of these patients. A high prevalence of malnutrition was also reported by Fiaccadori et al⁹ in a group of 55 COPD patients with ARF. However, in their study, the nutritional evaluation was not performed on admission but after at least two weeks of hospitalization; thus, the nutritional status could have been modified

REFERENCES (33)

DR Openbrier et al.
Nutritional status and lung function in patients with emphysema and chronic bronchitis
Chest
(1983)
SR Braun et al.
The prevalence and determinants of nutritional changes in chronic obstructive pulmonary disease
Chest
(1984)
A Schols et al.
Inventory of nutritional status in patients with COPD
Chest
(1989)
E Fiaccadori et al.
Hypercapnic-hypoxemic chronic obstructive pulmonary disease (COPD): influence of severity of COPD on nutritional status
Am J Clin Nutr
(1988)
JP Grant et al.
Current techniques of nutritional assessment
Surg Clin North Am
(1981)
CW Bishop et al.
Norms for nutritional assessment of American adults by upper arm anthropometry
Am J Clin Nutr
(1981)
GB Forbes et al.
Urinary creatinine excretion and lean body mass
Am J Clin Nutr
(1976)
AMWJ Schols et al.
Body composition by bioelectrical-impedance analysis compared with deuterium dilution and skinfold anthropometry in patients with chronic obstructive pulmonary disease
Am J Clin Nutr
(1991)
HC Lukaski
Methods for the assessment of human body composition: traditional and new
Am J Clin Nutr
(1987)
A Boulier et al.
Fat-free mass estimation by the two-electrod impedance method
Am J Clin Nutr
(1990)

MC Zillikens et al.

The validity of bioelectrical impedance analysis to estimate total body water in patients with cirrhosis of the liver [abstract]

Clin Nutr

(1991)

H Baier et al.

Ventilatory drive in normal man during semi-starvation

Chest

(1984)

AMB Hunter et al.

The nutritional status of patients with chronic obstructive pulmonary disease

Am Rev Respir Dis

(1981)

SM Kelly et al.

Inspiratory muscle strength and body composition in patients receiving total parenteral nutrition therapy

Am Rev Respir Dis

(1984)

J Askanazi et al.

Effect of protein intake on ventilatory drive

Anesthesiology

(1984)

GJ Gorse et al.

Association of malnutrition with nosocomial infection

Infect Control Hosp Epidemiol

(1989)

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: Manuscript received March 17; revision accepted August 12.

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Chest

Clinical InvestigationsNutritional Status of Patients With Chronic Obstructive Pulmonary Disease and Acute Respiratory Failure

Section snippets

Patients

Nutritional Assessment of the Total Population

DISCUSSION

Chest

Chest

Chest

Am J Clin Nutr

Surg Clin North Am

Am J Clin Nutr

Am J Clin Nutr

Am J Clin Nutr

Am J Clin Nutr

Am J Clin Nutr

Clin Nutr

Chest

The nutritional status of patients with chronic obstructive pulmonary disease

Am Rev Respir Dis

Inspiratory muscle strength and body composition in patients receiving total parenteral nutrition therapy

Am Rev Respir Dis

Effect of protein intake on ventilatory drive

Anesthesiology

Association of malnutrition with nosocomial infection

Infect Control Hosp Epidemiol

Clinical Investigations
Nutritional Status of Patients With Chronic Obstructive Pulmonary Disease and Acute Respiratory Failure