The positive role of nutritional support in the treatment of COVID-19 (Part 2)

Route of Nutrition Support

The last article sets forth the rationale for utilizing nutrition support among patients with pneumonia, and this section will review clinical outcomes brought by different routes of nutrition support, namely enteral nutrition (EN) and parenteral nutrition (PN). Although for elderly patients with severe pneumonia, some literatures pointed out that administering EN in conjunction with PN will result in more desirable clinical outcomes, particularly improved serum albumin, hemoglobin, and immunological parameters, than EN alone [1][2][3], elevated risk for infection that accompanies PN still concerns some.

In fact, one study on elderly patients with severe pneumonia indicated that PN leads to a higher overall adverse reaction rate (combined cases of elevated blood sugar, bloating, diarrhea, upper gastrointestinal tract bleeding, and compromised liver/kidney function) than EN (33.33% vs. 14.58%, respectively, p<0.05) [4]. Compared with PN only, several literatures demonstrated EN’s superiority in improving overall treatment efficiency (EN vs. PN: 94.74% vs. 78.95%), serum albumin, hemoglobin, serum immunological parameters, and nitrogen balance [5][6][7][8][9]. Moreover, EN is associated with preserving gut mucosal integrity, preventing bacterial translocation, and promoting gut motility, let alone its cost effectiveness compared with PN, explain why EN is generally considered preferable to PN. However, individual tolerance towards EN is another topic of discussion and will not be elaborated in this article.

With that being said, no one-size-fits-all nutrition support route will be feasible for implementing individual nutrition support, as clinical judgement (taking into account a patient’s disease state, disease stage, prognosis, etc.) is still required to make sound decisions regarding nutrition support route and transition schedule.

Nutrition Support Should Extend from Hospital to Home

Post-discharge nutrition intervention may be of equal importance to nutrition support during hospitalization. One study has concluded that elderly patients with pneumonia and malnutrition, who received individualized nutrition intervention program (intervention group) or family members receiving face to face nutrition consultation from a registered dietitian perform better in total energy intake, nutrition prescription adherence, and protein intake compares to the control group, which only received standard care. Although anthropometric values, blood biochemical parameters, and hospitalization length did not differ significantly, the intervention group, which continued to receive follow-up phone calls, showed sustained good energy intake and significantly better nutritional status 3 months and 6 months post discharge, with the re-admission rate being 77% lower than that of the control group [10]. The takeaway point is that nutrition intervention could be multidimensional, and the added benefits of nutrition intervention from hospital to home is a notable one.

Practical Challenges and Advantages of Medical Nutrition Products

Balanced nutrients are critical for achieving optimal clinical outcomes, but the complexity of patient conditions may present challenges for nutrition support, considering that human body in the disease state might react differently towards various nutrients.

For example, different polyunsaturated fatty acids ratio in nutrition support may result in differences in inflammatory response, immunological parameters, complications, ICU length, and protein synthesis [11]; high protein formula may reduce the risk for hypoproteinemia than its low protein isocaloric counterpart [12]; hypophasphatemia may weaken diaphragmatic contractility in patients with acute respiratory failure [13]. In addition, patients with pneumonia may encounter numerous obstacles in their nutrition support regimen: the disease status, for one, may cause loss of appetite, nausea and/or vomiting, which threatens adequate energy intake; patients on ventilators require nasogastric tube, PEG tube, or even parenteral nutrition for nutrition support, adding unpredictability to the nutrition intervention; other limitations of care, such as patients’ home diet being nutritionally incompetent, could also jeopardize timely recovery [14]. 

The aforementioned practical challenges bring up the next question: how to attain optimal nutrition intervention with possibly limited intake? Literatures mentioned above commonly adopt medical nutrition products as the nutrition intervention. Medical nutrition products, which are designed to meet specific requirements for macronutrients, micronutrients, fatty acid profile, certain enhanced nutrients, and even texture (water content, modified consistency, etc.), may stand out as a viable option for nutrition intervention. Given the extensive scientific research invested in formula development and the standardized factory production practice and quality control, industrialized medical nutrition products exhibit remarkable advantages in product consistency, stability, shelf-life, convenience, as well as being well-controlled for contamination risk than self-made homogenate diet products (commonly given in care facilities and/or home) [15]. Currently, medical nutrition products available to the market applies to much more conditions beyond just pneumonia (i.e. renal formula, diabetic formula, etc.), granting a wide array of treatment options for individualized nutrition therapy and benefiting patients as well as care providers.

Summary

Ample evidence has supported the benefits of incorporating nutrition intervention into disease treatment and management for patients with pneumonia. Choosing appropriate nutrition support route, closely monitoring nutritional status, and providing individualized, evidence-based nutrition therapy should be considered a crucial component in the journey of recovering from pneumonia.

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– About the authors – 

Lin Wan, MSc, RD

Lin is a nutrition specialist in Biofortis China. She manages operational aspects of clinical trials, coordinates communication among all stakeholders, and offers her professional insight from a nutritional perspective. Prior to joining Biofortis China, she worked as registered dietitian in hospitals and specializes in disease-specific nutrition intervention.

Dingqiang Li, Ph.D., DVM

Dr. Li leads the team responsible for implementation of clinical trials in China and he possesses rich experience in various aspects of conducting clinical trials. He closely works with Biofortis research centers in Europe and North America, clients and local key health professionals.

– References –

[1] Zhang, W.H. (2018) Effects of nutrition support in severe pneumonia treatment. Shanxi Medical Journal, 47(15), 56-57.DOI: 10.3969/j.issn.0253-9926.2018.15.023

[2] Yang, B., Zhu, X.H., & Lin, A.Q. (2017). Impact of nutrition support on treatment effect and immunological function in elderly patients with pulmonary infection and nutritional risk. Chinese Journal of Gerontology, 37(6), 1435-1437. DOI: 10.3969/j.issn.1005-9202.2017.06.057

[3] Liu, Y.F., Zheng, Y.S. (2017). Curative effect of enteral and parenteral nutrition support therapy in elderly patients with severe pneumonia. Parenteral & Enteral Nutrition, 2, 98-100.

[4] Yin, H.F., Wang, Q.G., Luo, D.D., & Liu, W.W. (2017). Clinical effects of enteral nutrition support in elderly patients with severe pneumonia. Contemporary Medicine, 23(28), 109-111. DOI: 10.3969/j.issn.1009-4393.2017.28.051

[5] Ji, S.T. (2016). Treatment effect observation of enternal and parenteral nutrition in elderly patients with severe pneumonia. The Medical Forum, S1, 9-11. DOI: 10.19435/j.1672-1721.2016.s1.007

[6] Qi, L., Sun, H.J., Zhao, Y.K., & Zhang, L.X. (2013). Effect of enteral and parenteral nutrition support in elderly patients with severe pneumonia. Chinese and Foreign Medical Research, 26, 116. DOI: 10.14033/j.cnki.cfmr.2013.26.062

[7] Hu, W.T., Liang Z.C. (2013). Efficacy of enteral nutrition in the treatment for elderly patients with severe pneumonia. Ningxia Medical Journal, 35(5), 401-403. 

[8] Zhang, B.M, Qin, W., Chen, D. Gao, J.J., Xu, J.L., & Pan, L.P. (2013). Clinical application of enteral nutrition in critically ill patients with mechanical ventilation. Parenteral & Enteral Nutrition, 20(5), 270-273. 

[9] Tang, Z.Q., Jia, L., Liu, Y., Gao, Y., Yu, K.J., & Wu, D.Q. (2014). Effect of Early Enteral Nutrition and Total Parenteral Nutrition in the Treatment for Patients with Severe Pneumonia in ICU. Progress in Modern Biomedicine, 14(30), 5880-5883.

[10] Yang, P.H., Lin, M.C., Liu, Y.Y., Lee, C.L., & Chang, N.J. (2019). Effect of Nutritional Intervention Programs on Nutritional Status and Readmission Rate in Malnourished Older Adults with Pneumonia: A Randomized Control Trial. International Journal of Environmental Research and Public Health, 16(23), 4758.

[11] Wang, Y.F., Fu, L., Wen, J.L., Chen, W.W., & Li, J.P. (2016). Influence of different ratio of polyunsaturated fatty acids on nutritional status, inflammatory response and prognosis in elderly patients with severe pneumonia. Chinese Community Doctors, 32(7), 98-99.

[12] Lu, W., Zheng, X., Tian, F., Gu, N.Y., Qiu, K., & Xiong, X.W. et al. (2018). Effect of enteral nutrition support containing equal non-protein calories but different protein contents on protein metabolism of elderly patients with severe pneumonia. Chinese Journal of Integrated Traditional and Western Medicine in Intensive and Critical Care, 25(1), 53-56. DOI: 10.3969/j.issn.1008-9691.2018.01.013

[13] Aubier, M., Murciano, D., Lecocguic, Y., Viires, N., Jacquens, Y., & Squara, P., et al. (1985). Effect of hypophosphatemia on diaphragmatic contractility in patients with acute respiratory failure. New England Journal of Medicine, 313(7), 420.

[14] Wu, N., Qi, Y.Q., Chen, X.S., & Wan, W.H. (2013). Clinical application of respiratory support combined with nutrition support in elderly patients with severe pneumonia. Chinese Journal of Multiple Organ Diseases in The Elderly, 12(1), 29-33.

[15] Yu, F.M., Shi, L., Li, K., Ning, N., Chen, M.J., & Hu, W. (2019). Comparison of nutrients between self-made homogenate diet and industrialized enteral nutrition product. Chinese Journal of Clinical Nutrition, 27(3), 173-178.