急性呼吸不全の栄養管理
急性呼吸不全は肺酸素化障害が主病態であり、原因は細菌性肺炎、誤嚥性肺炎、間質性肺炎、刺激性のガスの吸入、敗血症、多発性外傷、ショックなど数多くあり、それらは肺の直接障害によるものと全身性炎症反応の標的臓器となり発症する場合がある。治療は、原因への治療と呼吸循環をはじめとする全身管理で構成される。侵襲に伴い神経-内分泌-免疫系が賦活され代謝動態は異化亢進となる。さらに呼吸不全では呼吸仕事量の増加、挿管による新たな感染症のリスク、広域抗菌薬使用による正常細菌叢の乱れ、ステロイド使用による高血糖、喀痰力の維持改善の点からも全身管理の一環として代謝・栄養管理が重要であり、早期からの経腸栄養が推奨される...
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| Published in | 静脈経腸栄養 Vol. 27; no. 2; pp. 671 - 682 |
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| Main Author | |
| Format | Journal Article |
| Language | Japanese |
| Published |
日本静脈経腸栄養学会
2012
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| Subjects | |
| Online Access | Get full text |
| ISSN | 1344-4980 1881-3623 |
| DOI | 10.11244/jjspen.27.671 |
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| Abstract | 急性呼吸不全は肺酸素化障害が主病態であり、原因は細菌性肺炎、誤嚥性肺炎、間質性肺炎、刺激性のガスの吸入、敗血症、多発性外傷、ショックなど数多くあり、それらは肺の直接障害によるものと全身性炎症反応の標的臓器となり発症する場合がある。治療は、原因への治療と呼吸循環をはじめとする全身管理で構成される。侵襲に伴い神経-内分泌-免疫系が賦活され代謝動態は異化亢進となる。さらに呼吸不全では呼吸仕事量の増加、挿管による新たな感染症のリスク、広域抗菌薬使用による正常細菌叢の乱れ、ステロイド使用による高血糖、喀痰力の維持改善の点からも全身管理の一環として代謝・栄養管理が重要であり、早期からの経腸栄養が推奨される。初期投与設定では、熱量は25kcal/kg/日 (20≤BMI≤25) とし、使用する栄養剤は1.5～2.0kcal/mL濃度、タンパク質投与量は1.0-1.2g/kg/日、脂質含量15～30%を基準とし、血糖値は120～160mg/dLとする。炭酸ガス産生抑制が必要な病態では脂質含量を増やす。その後は血液生化学データの推移を確認し電解質および体液の厳密な管理を行い、その上で患者の個別性を反映 (投与熱量、タンパク質量の調節) した栄養管理を行う。ALI/ARDS症例へのn-3系脂肪酸、γリノレン酸、抗酸化物質を強化した栄養剤は現状では「考慮すべき」レベルである。 |
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| AbstractList | 急性呼吸不全は肺酸素化障害が主病態であり、原因は細菌性肺炎、誤嚥性肺炎、間質性肺炎、刺激性のガスの吸入、敗血症、多発性外傷、ショックなど数多くあり、それらは肺の直接障害によるものと全身性炎症反応の標的臓器となり発症する場合がある。治療は、原因への治療と呼吸循環をはじめとする全身管理で構成される。侵襲に伴い神経-内分泌-免疫系が賦活され代謝動態は異化亢進となる。さらに呼吸不全では呼吸仕事量の増加、挿管による新たな感染症のリスク、広域抗菌薬使用による正常細菌叢の乱れ、ステロイド使用による高血糖、喀痰力の維持改善の点からも全身管理の一環として代謝・栄養管理が重要であり、早期からの経腸栄養が推奨される。初期投与設定では、熱量は25kcal/kg/日 (20≤BMI≤25) とし、使用する栄養剤は1.5～2.0kcal/mL濃度、タンパク質投与量は1.0-1.2g/kg/日、脂質含量15～30%を基準とし、血糖値は120～160mg/dLとする。炭酸ガス産生抑制が必要な病態では脂質含量を増やす。その後は血液生化学データの推移を確認し電解質および体液の厳密な管理を行い、その上で患者の個別性を反映 (投与熱量、タンパク質量の調節) した栄養管理を行う。ALI/ARDS症例へのn-3系脂肪酸、γリノレン酸、抗酸化物質を強化した栄養剤は現状では「考慮すべき」レベルである。 |
| Author | 海塚, 安郎 |
| Author_FL | KAIZUKA Yasuo |
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| References | 25) Dent DL, Heyland DK, Levy H. Immunonutrition may increase mortality in critically ill patients with pneumonia: results of a randomized trial. Crit Care Med 30: 17-20, 2003. 27) Caparrós T, Lopez J, Grau T. Early enteral nutrition in critically ill patients with a high-protein diet enriched with arginine, fiber, and antioxidants compared with a standard high-protein diet. The effect on nosocomial infections and outcome. J Parenter Enteral Nutr 25: 299-308, 2001. 39) Jones C, Palmer TE, Griffiths RD. Randomized clinical outcome study of critically ill patients given glutamine-supplemented enteral nutrition. Nutrition 15: 108-15, 1999. 9) Guenst JM, Nelson LD. Predictors of total parenteral nutrition-induced lipogenesis. Chest 105: 553-9, 1994. 20) Wolfe RR, Goodenough RD, Burke JF, et al. Response of protein and urea kinetics in burn patients to different levels of protein intake. Ann Surg 197: 163-71, 1983. 50) Nathens AB, Neff MJ, Jurkovich GJ, et al. Randomized, prospective trial of antioxidant supplementation in critically ill surgicalpatients. Ann Surg 236: 814-22, 2002. 40) Goeters C, Wenn A, Mertes N, et al. Parenteral L-alanyl-L-glutamine improves 6-month outcome in critically ill patients. Crit Care Med 30: 2032-7, 2002. 47) Van Way CW 3rd, Moore EE, Allo M, et al. Comparison of total parenteral nutrition with 25 per cent and 45 per cent branched chain amino acids in stressed patients. Am Surg 1985; 51: 609-16, 1985. 14) Mesejo A, Acosta JA, Ortega C, et al. Comparison of a high-protein disease-specific enteral formula with a high-protein enteral formula in hyperglycemic critically ill patients. Clin Nutr 22: 295-305, 2003. 26) Bower RH, Cerra FB, Bershadsky B, et al. Early enteral administration of a formula (Impact) supplemented with arginine, nucleotides, and fish oil in intensive care unit patients: results of a multicenter, prospective, randomized, clinical trial. Crit Care Med 23: 436-49, 1995. 56) Singer P, Anber R, Cohen J, et al. The tight calorie control study(TICACOS): a prospective, randomized, controlled pilot study of nutritional support in critically ill patients. Intensive Care Med 37: 601-9, 2011. 49) von Meyenfeldt MF, Soeters PB, Vente JP, et al. Effect of branched chain amino acid enrichment of total parenteral nutrition on nitrogen sparing and clinical outcome of sepsis and trauma: a prospective randomized double blind trial. Br J Surg 77: 924-9, 1990. 1) 海塚安郎. 急性呼吸不全に対する栄養管理時の水・電解質の基本的考え方. 井上善文編. 臨床栄養別冊6栄養療法に必要な水・電解質代謝の知識. 医歯薬出版株式会社、東京、2011、p116-124. 3) Tappy L, Berger M, Schwarz J-M, et al. Hepatic and peripheral glucose metabolism in intensive care patients receiving continuous high- or low-carbohydrate enteral nutrition. J Parenter Enteral Nutr 23: 260-8, 1999. 54) Mishra V, Baines M, Elizabeth P, et al. Effect of selenium supplementation on biochemical markers and outcome in critically ill patients. Clin Nutr 26: 41-50, 2007. 28) Kieft H, Roos A, Bindels A, et al: Clinical Outcome of an Immune Enhancing Diet in a Heterogenous Intensive Care population. Intensive Care Med 31: 524-32, 2005. 6) Acheson KJ, Schutz Y, Bessard T, et al. Glycogen storage capacity and de novo lipogenesis during massive carbohydrate overfeeding in man. Am J Clin Nutr 48: 240-7, 1988. 44) Avenell A. Hot topics in parenteral nutrition. Current evidence and ongoing trials on the use of glutamine in critically-ill patients and patients undergoing surgery. Proc Nutr Soc 68: 261-8, 2009. 51) Crimi E, Liguori A, Condorelli M, et al. The beneficial effects of antioxidant supplementation in enetral feeding incritically illpatients: a prospective, randomized, double-blind, placebo-controlled trial. Anesth Analg 99: 857-63, 2004. 7) Askanazi J, Rosenbaum S, Hyman A, et al. Respiratory changes induced by the large glucose loads of total parenteral nutrition. JAMA 243: 1444-7, 1980. 15) Iriyama K, Tonouchi H, Azuma T, et al. Capacity of high-density lipoprotein for donating apolipoproteins to fat particules in hypertriglyceridemia induced by fat infusion. Nutrition 7: 355-7, 1991. 12) van den Berg B, Bogaard JM, Hop WC. High fat, low carbohydrate, enteral feeding in patients weaning from the ventilator. Intensive Care Med 20: 470-5, 1994. 32) Garrel D, Patenaude J, Nedelec B, et al. Decreased mortality and infectious morbidity in adult burn patients given enteral glutamine supplements: a prospective, controlled, randomized clinical trial. Crit Care Med 31: 2444-29, 2003. 37) Brantley S, Pierce J. Effects of enteral glutamine on trauma patients. Nutr Clin Pract 15: S13, 2000. 41) Déchelotte P, Hasselman M, Cynober L, et al. L-Alanyl-L-glutamine dipeptide-supplemented totalparenteral nutrition reduces infectious complications and glucose intolerance in critically ill patients : The French controlled, randomized, double-blind, multicentre study. Crit Care Med 34: 598-604, 2006. 16) Gadek JE, DeMichele SL, Karlstad MD et al. Effect of enteral feeding with eicosapentaenoic acid, gammalinolenic acid, and antioxidants in patients with acute respiratory distress syndrome. Crit Care Med 27: 1409-20, 1999 30) Heyland DK, Dhaliwal R, Drover JW, et al. Canadian Critical Care Clinical PracticeGuidelines Committee:Canadian clinical practice guidelines for nutrition support in mechanically ventilated, critically ill adult patients. J Parenter Enteral Nutr 27: 355-73, 2003. 34) Houdijk AP, Rijnsburger ER, Jansen J, et al. Randomised trial of glutamine-enriched enteral nutrition on infectious morbidity in patients with multiple trauma. Lancet 352: 772-6, 1998. 22) Larsson J, Lennmarken C, Martensson J, et al. Nitrogen requirements in severely injured patients. Br J Surg 77: 413-6, 1990. 17) Singer P, Theilla M, Fisher H et al. Benefit of an enteral diet enriched with eicosapentaenoic acid and gamma-linolenic acid in ventilated patients with acute lung injury. Crit Care Med 34: 1033-8, 2006. 31) January 31st 2009 Canadian Clinical Practice Guidelines update. http://www.criticalcarenutrition.com 4) Sakurai Y, Aarsland A, Herndon D, et al. Stimulation of muscle proein synthesis by long-term insulin infusion in severely burned patients. Ann Surg 222: 283-94, 1995. 53) Angstwurm MWA, Schottdorf J, Schopohl J, et al. Selenium replacement in patients with severe systemic inflammatory response syndrome improves clinical outcome. Crit Care Med 27: 1807-13, 1999. 11) McClave SA, Lowen CC, Kleber MJ, et al. Clinical use of the respiratory quotient obtained from indirect calorimetry. JPEN J Parenter Enteral Nutr 27: 21-6, 2003. 19) Rice TW, Wheeler AP, Thompson BT, et al. Enteral omega-3 fatty acid, gamma-linolenicacid, and antioxidant supplementation in acute lung injury. JAMA 306: 1574-81, 2011. 10) Liposky JM, Nelson LD. Ventilatory response to high caloric loads in critically ill patients. Crit Care Med 25: 796-802, 1994. 18) Pontes-Arruda A, Aragao AM, Albuquerque JD et al. Effects of enteral feeding with eicosapentaenoic aicd, gamma-linolenic acid, and antioxidants in mechanically ventilated patients with severe sepsis and septic shock. Crit Care Med 34: 2325-33, 2006. 21) Shaw J, Wildbore M, Wolfe R. Whole body proteinkinetics in severely septic patients. The response to glucose infusion and total parenteral nutrition. Ann Surg 205: 288-94, 1987. 24) Galbán C, Montejo JC, Mesejo A, et al. An immune-enhancing enteral diet reduces mortality rate and episodes of bacteremia in septic intensive care unit patients. Crit Care Med 28: 643-8, 2000. 55) Forceville X, Laviolle B, Annane D, et al. Effects of high doses of selenium, as sodium selenite, in septic shock: a placebo-controlled, randomized, double-blind, phase II study. Crit Care 11: R73, 2007. 38) McQuiggan M, Kozar R, Sailors RM, et al: Enteral glutamine during active shock resuscitation is safe and enhances tolerance of enteral feeding. J Parenter Enteral Nutr 32: 28-35, 2008. 8) Frayn KN. Calculation of substrate oxidation rates in vivo from gaseous exchange. J Appl Physiol; 55, 628-34, 1983. 48) Kuhl DA, Brown RO, Vehe KL, et al. Use of selected visceral protein measurements in the comparison of branched-chain amino acids with standard amino acids in parenteral nutrition support of injured patients. Surgery 107: 503-10, 1990. 13) al-Saady NM, Blackmore CM, Bennett ED. High fat, low carbohydrate, enteral feeding lowers PaCO2 and reduces the period of ventilation in artificially ventilated patients. Intensive Care Med 15: 290-5, 1989. 2) 日本呼吸療法医学会栄養管理ガイドライン作成委員会. 急性呼吸不全による人工呼吸患者の栄養管理に関するガイドライン. 人工呼吸 27: 75-118. 2010. 52) Angstwurm MWA, Engelmann L, Zimmermann T, et al. Selenium in intensive care(SIC): Results of a prospective randomized, placebo-controlled, multi-center study in patients with severe systemic inflammatory response syndrome, sepsis, and septic shock. Crit Care Med 35: 118-26, 2007. 29) Bertolini G, Iapichino G, Radrizzani D, et al. Early enteral immunonutrition in patients with severe sepsis: results of an interim analysis of a randomized multicentre clinical trial. Intensive Care Med 29: 834-40, 2003. 42) Estivariz CF, Griffith DP, Luo M, et al. Efficacy of parenteral nutrition supplemented with glutamine dipeptide to decrease hospital infections in critically ill surgical patients. J Parenter Enteral Nutr 32: 389-402, 2009. 43) Fuentes-Oroczo C, Cervantes-Guevara G, Mucino-Hernández I, et al: L-alanyl-L-glutamine-supplemented parenteral nutrition decreases infectious morbidity rate in patients with severe acute pancreatitis. J Parenter Enteral Nutr 32: 403-11, 2008. 57) Casaer MP, Mesotten D, Hermans G, et al. Early versus late parenteral nutrition in critically ill adults. N Engl J Med 365: 506-17, 2011. 36) Hall JC, Dobb G, Hall J, et al. A prospective randomized trial of enteral glutamine in critical illness. Intensive Care Med 29: 1710-6, 2003. 35) Zhou YP, Jiang ZM, Sun YH, et al. The effect of supplemental enteral glutamine on plasma levels, gut function, and outcome in severe burns: a randomized, double-blind, controlled clinical trial. J Parenter Enteral Nutr 27: 241-5, 2003. 45) Luo M, Bazargan N, Griffith |
| References_xml | – reference: 3) Tappy L, Berger M, Schwarz J-M, et al. Hepatic and peripheral glucose metabolism in intensive care patients receiving continuous high- or low-carbohydrate enteral nutrition. J Parenter Enteral Nutr 23: 260-8, 1999. – reference: 18) Pontes-Arruda A, Aragao AM, Albuquerque JD et al. Effects of enteral feeding with eicosapentaenoic aicd, gamma-linolenic acid, and antioxidants in mechanically ventilated patients with severe sepsis and septic shock. Crit Care Med 34: 2325-33, 2006. – reference: 49) von Meyenfeldt MF, Soeters PB, Vente JP, et al. Effect of branched chain amino acid enrichment of total parenteral nutrition on nitrogen sparing and clinical outcome of sepsis and trauma: a prospective randomized double blind trial. Br J Surg 77: 924-9, 1990. – reference: 12) van den Berg B, Bogaard JM, Hop WC. High fat, low carbohydrate, enteral feeding in patients weaning from the ventilator. Intensive Care Med 20: 470-5, 1994. – reference: 41) Déchelotte P, Hasselman M, Cynober L, et al. L-Alanyl-L-glutamine dipeptide-supplemented totalparenteral nutrition reduces infectious complications and glucose intolerance in critically ill patients : The French controlled, randomized, double-blind, multicentre study. Crit Care Med 34: 598-604, 2006. – reference: 15) Iriyama K, Tonouchi H, Azuma T, et al. Capacity of high-density lipoprotein for donating apolipoproteins to fat particules in hypertriglyceridemia induced by fat infusion. Nutrition 7: 355-7, 1991. – reference: 51) Crimi E, Liguori A, Condorelli M, et al. The beneficial effects of antioxidant supplementation in enetral feeding incritically illpatients: a prospective, randomized, double-blind, placebo-controlled trial. Anesth Analg 99: 857-63, 2004. – reference: 24) Galbán C, Montejo JC, Mesejo A, et al. An immune-enhancing enteral diet reduces mortality rate and episodes of bacteremia in septic intensive care unit patients. Crit Care Med 28: 643-8, 2000. – reference: 53) Angstwurm MWA, Schottdorf J, Schopohl J, et al. Selenium replacement in patients with severe systemic inflammatory response syndrome improves clinical outcome. Crit Care Med 27: 1807-13, 1999. – reference: 22) Larsson J, Lennmarken C, Martensson J, et al. Nitrogen requirements in severely injured patients. Br J Surg 77: 413-6, 1990. – reference: 20) Wolfe RR, Goodenough RD, Burke JF, et al. Response of protein and urea kinetics in burn patients to different levels of protein intake. Ann Surg 197: 163-71, 1983. – reference: 21) Shaw J, Wildbore M, Wolfe R. Whole body proteinkinetics in severely septic patients. The response to glucose infusion and total parenteral nutrition. Ann Surg 205: 288-94, 1987. – reference: 55) Forceville X, Laviolle B, Annane D, et al. Effects of high doses of selenium, as sodium selenite, in septic shock: a placebo-controlled, randomized, double-blind, phase II study. Crit Care 11: R73, 2007. – reference: 2) 日本呼吸療法医学会栄養管理ガイドライン作成委員会. 急性呼吸不全による人工呼吸患者の栄養管理に関するガイドライン. 人工呼吸 27: 75-118. 2010. – reference: 11) McClave SA, Lowen CC, Kleber MJ, et al. Clinical use of the respiratory quotient obtained from indirect calorimetry. JPEN J Parenter Enteral Nutr 27: 21-6, 2003. – reference: 1) 海塚安郎. 急性呼吸不全に対する栄養管理時の水・電解質の基本的考え方. 井上善文編. 臨床栄養別冊6栄養療法に必要な水・電解質代謝の知識. 医歯薬出版株式会社、東京、2011、p116-124. – reference: 10) Liposky JM, Nelson LD. Ventilatory response to high caloric loads in critically ill patients. Crit Care Med 25: 796-802, 1994. – reference: 27) Caparrós T, Lopez J, Grau T. Early enteral nutrition in critically ill patients with a high-protein diet enriched with arginine, fiber, and antioxidants compared with a standard high-protein diet. The effect on nosocomial infections and outcome. J Parenter Enteral Nutr 25: 299-308, 2001. – reference: 7) Askanazi J, Rosenbaum S, Hyman A, et al. Respiratory changes induced by the large glucose loads of total parenteral nutrition. JAMA 243: 1444-7, 1980. – reference: 17) Singer P, Theilla M, Fisher H et al. Benefit of an enteral diet enriched with eicosapentaenoic acid and gamma-linolenic acid in ventilated patients with acute lung injury. Crit Care Med 34: 1033-8, 2006. – reference: 33) Peng X, Yan H, You Z, et al. Effects of enteral supplementation with glutamine granules on intestinal mucosal barrier function in severe burned patients. Burns 30: 135-9, 2004. – reference: 39) Jones C, Palmer TE, Griffiths RD. Randomized clinical outcome study of critically ill patients given glutamine-supplemented enteral nutrition. Nutrition 15: 108-15, 1999. – reference: 30) Heyland DK, Dhaliwal R, Drover JW, et al. Canadian Critical Care Clinical PracticeGuidelines Committee:Canadian clinical practice guidelines for nutrition support in mechanically ventilated, critically ill adult patients. J Parenter Enteral Nutr 27: 355-73, 2003. – reference: 52) Angstwurm MWA, Engelmann L, Zimmermann T, et al. Selenium in intensive care(SIC): Results of a prospective randomized, placebo-controlled, multi-center study in patients with severe systemic inflammatory response syndrome, sepsis, and septic shock. Crit Care Med 35: 118-26, 2007. – reference: 29) Bertolini G, Iapichino G, Radrizzani D, et al. Early enteral immunonutrition in patients with severe sepsis: results of an interim analysis of a randomized multicentre clinical trial. Intensive Care Med 29: 834-40, 2003. – reference: 14) Mesejo A, Acosta JA, Ortega C, et al. Comparison of a high-protein disease-specific enteral formula with a high-protein enteral formula in hyperglycemic critically ill patients. Clin Nutr 22: 295-305, 2003. – reference: 35) Zhou YP, Jiang ZM, Sun YH, et al. The effect of supplemental enteral glutamine on plasma levels, gut function, and outcome in severe burns: a randomized, double-blind, controlled clinical trial. J Parenter Enteral Nutr 27: 241-5, 2003. – reference: 37) Brantley S, Pierce J. Effects of enteral glutamine on trauma patients. Nutr Clin Pract 15: S13, 2000. – reference: 56) Singer P, Anber R, Cohen J, et al. The tight calorie control study(TICACOS): a prospective, randomized, controlled pilot study of nutritional support in critically ill patients. Intensive Care Med 37: 601-9, 2011. – reference: 8) Frayn KN. Calculation of substrate oxidation rates in vivo from gaseous exchange. J Appl Physiol; 55, 628-34, 1983. – reference: 19) Rice TW, Wheeler AP, Thompson BT, et al. Enteral omega-3 fatty acid, gamma-linolenicacid, and antioxidant supplementation in acute lung injury. 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| Title | 急性呼吸不全の栄養管理 |
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