Micronutrients as immunomodulatory tools for COVID-19 management.

COVID-19 rapidly turned to a global pandemic posing lethal threats to overwhelming health care capabilities, despite its relatively low mortality rate. The clinical respiratory symptoms include dry cough, fever, anosmia, breathing difficulties, and subsequent respiratory failure. No known cure is available for COVID-19. Apart from the anti-viral strategy, the supports of immune effectors and modulation of immunosuppressive mechanisms is the rationale immunomodulation approach in COVID-19 management. Diet and nutrition are essential for healthy immunity. However, a group of micronutrients plays a dominant role in immunomodulation. The deficiency of most nutrients increases the individual susceptibility to virus infection with a tendency for severe clinical presentation. Despite a shred of evidence, the supplementation of a single nutrient is not promising in the general population. Individuals at high-risk for specific nutrient deficiencies likely benefit from supplementation. The individual dietary and nutritional status assessments are critical for determining the comprehensive actions in COVID-19.

Initial nutritional management during noninvasive ventilation and outcomes: a retrospective cohort study.

BACKGROUND: Patients starting noninvasive ventilation (NIV) to treat acute respiratory failure are often unable to eat and therefore remain in the fasting state or receive nutritional support. Maintaining a good nutritional status has been reported to improve patient outcomes. In the present study, our primary objective was to describe the nutritional management of patients starting first-line NIV, and our secondary objectives were to assess potential associations between nutritional management and outcomes. METHODS: Observational retrospective cohort study of a prospective database fed by 20 French intensive care units. Adult medical patients receiving NIV for more than 2 consecutive days were included and divided into four groups on the basis of nutritional support received during the first 2 days of NIV: no nutrition, enteral nutrition, parenteral nutrition only, and oral nutrition only. RESULTS: Of the 16,594 patients admitted during the study period, 1075 met the inclusion criteria; of these, 622 (57.9%) received no nutrition, 28 (2.6%) received enteral nutrition, 74 (6.9%) received parenteral nutrition only, and 351 (32.7%) received oral nutrition only. After adjustment for confounders, enteral nutrition (vs. no nutrition) was associated with higher 28-day mortality (adjusted HR, 2.3; 95% CI, 1.2-4.4) and invasive mechanical ventilation needs (adjusted HR, 2.1; 95% CI, 1.1-4.2), as well as with fewer ventilator-free days by day 28 (adjusted relative risk, 0.7; 95% CI, 0.5-0.9). CONCLUSIONS: Nearly three-fifths of patients receiving NIV fasted for the first 2 days. Lack of feeding or underfeeding was not associated with mortality. The optimal route of nutrition for these patients needs to be investigated.

Impact of Individualized Diet Intervention on Body Composition and Respiratory Variables in Children With Respiratory Insufficiency: A Pilot Intervention Study.

OBJECTIVES: Diet modification may improve body composition and respiratory variables in children with respiratory insufficiency. Our objective was to examine the effect of an individualized diet intervention on changes in weight, lean body mass, minute ventilation, and volumetric CO2 production in children dependent on long-term mechanical ventilatory support. DESIGN: Prospective, open-labeled interventional study. SETTING: Study subjects' homes. PATIENTS: Children, 1 month to 17 years old, dependent on at least 12 hr/d of transtracheal mechanical ventilatory support. INTERVENTIONS: Twelve weeks of an individualized diet modified to deliver energy at 90-110% of measured energy expenditure and protein intake per age-based guidelines. MEASUREMENTS AND MAIN RESULTS: During a multidisciplinary home visit, we obtained baseline values of height and weight, lean body mass percent by bioelectrical impedance analysis, actual energy and protein intake by food record, and measured energy expenditure by indirect calorimetry. An individualized diet was then prescribed to optimize energy and protein intake. After 12 weeks on this interventional diet, we evaluated changes in weight, height, lean body mass percent, minute ventilation, and volumetric CO2 production. Sixteen subjects, mean age 9.3 years (SD, 4.9), eight male, completed the study. For the diet intervention, a majority of subjects required a change in energy and protein prescription. The mean percentage of energy delivered as carbohydrate was significantly decreased, 51.7% at baseline versus 48.2% at follow-up, p = 0.009. Mean height and weight increased on the modified diet. Mean lean body mass percent increased from 58.3% to 61.8%. Minute ventilation was significantly lower (0.18 L/min/kg vs 0.15 L/min/kg; p = 0.04), and we observed a trend toward lower volumetric CO2 production (5.4 mL/min/kg vs 5.3 mL/min/kg; p = 0.06) after 12 weeks on the interventional diet. CONCLUSIONS: Individualized diet modification is feasible and associated with a significant decrease in minute ventilation, a trend toward significant reduction in CO2 production, and improved body composition in children on long-term mechanical ventilation. Optimization of respiratory variables and lean body mass by diet modification may benefit children with respiratory insufficiency in the ICU.

Manejo nutricional en un paciente con VIH e insuficiencia respiratoria aguda tipo I / Nutritional management in a patient with HIV and acute respiratory failure tipe I

Paciente de sexo masculino, de 31 años de edad. HIV (+) desde hace 1 año. Se encontraba recibiendo TARGA; acude al HNDAC por presentar disnea, tos persistente, secreciones mucopurulentas amarillo-verdosas, náuseas. Ingresó por cuadro de Insuficiencia Respiratoria Aguda (IRA tipo 1) al servicio de Unidad de Cuidados Intensivos del Hospital Nacional Daniel Alcides Carrión en Julio de 2013. Al momento de la Intervención Nutricional se le venía haciendo manejo ventilatorio y control hemodinámico. Sala: Unidad de Cuidados Intensivos. Edad: 31 años. Sexo: Masculino, Fecha de ingreso al hospital: 17/07/2013, Fecha de ingreso a servicio: 18/07/2013, Diagnóstico médico: IRA Tipo I en VM, por NAC, Hemoptisis inactiva, VIH (+) en TARGAy alcalosis respiratoria.

Male patient, 31 years of age. He is HIV (+) for 1 year. Patient is receiving Highly Active Antiretroviral Treatmen (HAART). Pacient arrives to Daniel Alcides Carrión Hospital in Callao because of symtoms such as breathlessness, persistent cough, yellow-green mucopurulent secretions, nausea. Patient is admitted to Intensive Care Unit with Respiratory failure in July 2013. At the moment of the Nutritional Intervention, patient was receiving ventilatory managament and hemodinamic con Room: Intensive Care Unit. Age: 31 years. Gender: Male. Hospital admission date: 17/07/2013. Service entry date: 1 8/07/201 3. Medical diagnosis: IRA VM Type 1, by NAC, Hemoptysis inactive HIV (+) on HAART and respiratory alkalosis.

Manejo nutricional de un paciente con sepsis e insuficiencia respiratoria aguda con apoyo de oxígeno / Nutritional management in a patient with sepsis and respiratory failure acute oxygen to support

Paciente masculino de 53 años de edad, ingresa al hospital Daniel Alcides Carrión por emergencia el día 21 de enero por presentar graves problemas respiratorios y sensación de ahogo, por lo cual es ingresado en la Unidad de Cuidados Intensivos (UCI) con el fin de estabilizarlo. Sala: UCI . Fecha de nacimiento: 11 de noviembre de 1976. Edad: 53 años. Sexo: Masculino. Fecha de ingreso al hospital: 21/01/2013 Fecha de ingreso a servicio: 22/03/2013. Diagnóstico médico: Insuficiencia Respiratoria Aguda c/ apoyo de Oxígeno, sepsis (foco pulmonar), pericarditis, hipertensión arterial.

Male patient, 53 years of age admitted to the hospital for emergency Daniel Alcides Carrion on January 21 to present serious breathing problems and shortness of breath, so it is entered into the Intensive Care Unit (ICU) in orderto stabilize. Room:UCI. Age: 53 years ~ Gender: Male. Hospital admission date: 21/01/2013. Service entry date: 22/03/2013. Medical diagnosis: Acute respiratory failure w / support from 02, sepsis (pulmonary area) , pericarditis, hypertension.

Manejo nutricional en un paciente con insuficiencia respiratoria crónica con oxigenoterapia / Nutritional management in a patient with chronic respiratory failure and oxigen therapy

Paciente masculino, 66 años de edad. Hace 7 meses hace 7 meses diagnosticado con linfoma B difuso células grandes EC IV; días antes del ingreso al hospital presenta dificultad deglutir alimentos sólidos; no presenta nauseas ni vómitos; 3 días antes del ingreso al hospital presenta dificultad para deglutir líquidos. Esta dificultad para deglutir es acompañada por la dificultad para respirar, motivo por el cual es llevado a emergencia. Sala: Medicina 7° B; fecha de nacimiento; 25 de julio de 1946; edad: 66 años; sexo, masculino; fecha de ingreso al hospital: 02/11/2012; fecha de ingreso a servicio: 03/11/2012; diagnóstico médico: insuficiencia respiratoria crónica con oxigenoterapia, linfoma B celular difuso EC IV.

Male patient, 66 years old. Patient was diagnosed with diffuse large cell lymphoma B EC IV; Five days before his admission into the hospital, patient had some difficulties in swallowing solid food; patients not present nausea or vomiting. There days before his admission into the hospital, patient presented difficulties in swallowing liquids accompanied by shortness of breath, because of that, patient is taken to hospital emergency wasd.Room: Surgery 7th; date of birth: 25 July, 1946; Age: 66 years; Gender: male; hospital admission date: 02/11/2012; Service admission date: 03/11/2012; medical diagnosis: chronic respiratory failure, nutritional management.

Algoritmo de utilización de fórmulas de nutrición enteral / Algorithm for the use of enteral nutrition formulas

Teniendo en cuenta la clasificación más utilizada sobre fórmulas de nutrición enteral, podemos dividirlas en poliméricas (normoproteínicas, normoproteínicas concentradas, normoproteínicas con fibra, hiperproteínicas), oligomonoméricas (peptídicas normoproteínicas, peptídicas hiperproteínicas, aminoácidos libres) y especiales (nefropatía, hepatopatía crónica, hiperglucemia, insuficiencia respiratoria, situaciones críticas e inmunomoduladoras). Uno de los mayores avances existentes en la actualidad se sitúa en las fórmulas especiales, por ello revisaremos el nivel de evidencia en esta área. Podemos decir que, con un grado de recomendación A, se debe indicar fórmulas especiales con proteínas escasas a pacientes en insuficiencia renal crónica fuera de un programa de hemodiálisis. Con un grado de recomendación A, podemos decir que se debe indicar las fórmulas pobres en proteínas y enriquecidas en aminoácidos de cadena ramificada a los pacientes con encefalopatía hepática que no toleran una cantidad normal de proteínas. Se puede recomendar con un grado A la utilización de fórmulas ricas en grasas a los pacientes con diabetes mellitus mal controlados o con hiperglucemia de estrés. Y podemos recomendar con un grado A la utilización de fórmulas con distribución convencional de macronutrientes a los pacientes con insuficiencia respiratoria. En resumen, la utilización de las fórmulas de nutrición enteral no debe ser analizada de un modo aislado, y se debe valorar desde el punto de vista de un paciente para el que tenemos que analizar el tipo de nutrición, la vía de acceso y el tipo de administración, y en esta cascada de ideas, valorar el tipo de fórmula enteral

Enteral nutrition formulas can be divided into the following groups; polymeric (normoproteic, normoproteic calorie-enhanced, normoproteic with fiber, hyperproteic), oligomonomeric (peptidic normoproteic, peptidic hyperproteic with amino acids) and special (kidney disease, chronic liver disease, hyperglycemia, respiratory insufficiency, critical care patients and immunonutrient-enhanced formulas). Special formulas have improved rapidly and consequently the level of evidence in this area is reviewed. Low protein formulas can be recommended (Level A) in patients with chronic kidney disease not undergoing dialysis. Low protein formulas enhanced with branch chain amino acids can be recommended (Level A) in patients with liver encephalopathy unable to tolerate normal oral dietary protein intake. Formulas enriched with monounsaturated fatty acids can be used (Level A) in diabetic patients with poor metabolic control or stress hyperglycemia. Formulas with a normal macronutrient composition can be recommended (Level A) in patients with respiratory insufficiency. When analyzing the use of enteral nutrition formulas in clinical practice, the following factors should be taken into account: the type of nutrition, route of access, type of administration, and the type of enteral formula used

[Nutrition and respiratory insufficiency]. / Nutrición e insuficiencia respiratoria.

Unlike other pathologies, not much attention has been paid to the relationship between nutrition and respiratory disease. This is probably because some of these diseases, such as cancer and chronic obstructive pulmonary disease, are closely associated with smoking while others that could be more directly linked with nutrition such as cystic fibrosis and emphysema are not directly caused by nutrition disorders. Not all patients with chronic obstructive pulmonary disease are undernourished. When malnutrition is present in these patients it is because of multiple reasons and is associated with an increase in both mortality and morbidity. In patients with acute respiratory insufficiency, malnutrition is often secondary to a heightened catabolic state leading to the severe fundamental illness. We also know that nutritional treatment may not only correct malnutrition but also help in improving the respiratory function. This nutritional therapy is not normally easy to comply with. It must be accompanied by other non-pharmacological therapies such as rehabilitation. Renourishment may also entail risks for patients with respiratory diseases so it is very important to know as closely as possible their nutritional requirements and to focus on specific actions.

PC program for simultaneously testing equality of means and variances for paired bivariate normal data.

A menu-driven PC program for simultaneously testing the equality of means and variances for paired bivariate normal data is described, illustrated and made available. While the corresponding tests for independent samples are well-known and widely implemented, in the paired situation only the test for no change in mean values (the paired t-test) has been similarly covered. Tests for no change in variability, while important, are less well-known and not implemented in most commercial statistical computing programs.

High fat, low carbohydrate, enteral feeding lowers PaCO2 and reduces the period of ventilation in artificially ventilated patients.

The objective of this study was to compare the effect of a high fat, low carbohydrate enteral feed with a standard isocaloric, isonitrogenous enteral feed on PaCO2 and ventilation time in patients with acute respiratory failure requiring artificial ventilation. 20 clinically stable patients requiring enteral feeding were randomized to either feed in a double-blind fashion. Initial ventilator standard settings were adjusted according to clinical state. Measurements including minute volume and arterial blood gases were made twice daily. Weaning was carried out according to set criteria. During the feeding period, PaCO2 just prior to weaning fell by 16% in the high fat group but increased by 4% in the standard feed group (p = 0.003). The high fat group spent a mean of 62 h less time on the ventilator (p = 0.006). A high fat, low carbohydrate enteral feed appears to be beneficial in patients undergoing artificial ventilation.

Acid maltase deficiency in an adult. Evidence for improvement in respiratory function with high-protein dietary therapy.

Acid maltase deficiency (AMD) in the adult is associated with progressive ventilatory muscle weakness and death from respiratory failure, but effective therapy is not available at present. Because recent evidence suggests that muscle catabolism may contribute to muscle weakness in AMD, we treated a 55-yr-old man with AMD and severe ventilatory muscle weakness with a high-protein (1.6 g/kg), weight-reducing diet for 27 months. High-protein dietary therapy was associated with striking improvement in respiratory function, including measures of ventilatory muscle strength and endurance. We suggest that high-protein dietary therapy may be useful in adults with AMD and respiratory insufficiency.

Effect of low calorie intake on abnormal pulmonary physiology in patients with chronic hypercapneic respiratory failure.

To explore the effects of low calorie, low carbohydrate intake on abnormal pulmonary physiology in chronic hypercapneic respiratory failure, spirometric, arterial blood gas tension, oximetric, and electrocardiographic studies were carried out before and after weight reduction in eight patients. During a single night of monitoring, the mean basal oxygen saturation was 68.4 +/- 20.7 percent with 38 hypoxemic "dips" (a fall in oxygen saturation of more than 10 percent for one minute or longer); six patients had resting tachycardia, four had a prolonged QTc interval, three showed multiple episodes of ST-T depression, and six patients had multiple atrial and ventricular premature contractions. After a low calorie (600 kcal per day) intake for 4.4 +/- 2.3 weeks, there was a mean weight loss of 8.5 +/- 3.6 kg, the mean arterial oxygen tension increased significantly (p less than 0.005) from 55.6 +/- 9.2 to 69.1 +/- 7.9 torr, the mean arterial carbon dioxide tension fell from 59.9 +/- 9.6 to 52.4 +/- 5.4 torr (p less than 0.01), the mean oxygen saturation increased significantly (p less than 0.05) to 85.0 +/- 9.0 percent with only two hypoxemic "dips," the resting heart rate decreased from a mean of 100 +/- 19 to 90 +/- 18 beats/per minute (p less than 0.05), there was a marked reduction in ectopic activity, the ST-T depression disappeared, and the QTc interval fell in two subjects. Follow-up data in four patients suggest that the improvements achieved in arterial blood gas values can be maintained with a low calorie intake. These studies show that a low calorie, low carbohydrate intake improves all the unfavorable physiologic abnormalities in chronic hypercapneic respiratory failure.

A procedure for management of acquired tracheoesophageal fistula in ventilator patients.

An operative technique is presented for acquired tracheosophageal fistula including cervical esophagostomy, division and closure of the distal esophagus, and use of the cervical and thoracic esophageal segment as a patch to close the posterior trachea wall. Later coloesophagoplasty is used to establish gastrointestinal continuity. An external negative-pressure ventilator (Drinker-Collins iron lung) is used in combination with a conventional positive-pressure ventilator to diminish airway pressure after the tracheal repair.