Nutritional management of COVID-19 patients in a rehabilitation unit
Nutritional management of COVID-19 patients in a rehabilitation unit
复制标题
DOI：
10.1038/s41430-020-0664-x
复制
发表时间：
2020-05-20
影响因子：
4.7
通讯作者：
Iannaccone, Sandro
中科院分区：
文献类型：
--
作者：
Brugliera, Luigia;Spina, Alfio;Iannaccone, Sandro
严重急性呼吸综合征冠状病毒2(SARS-CoV-2)使医疗保健系统组织，特别是意大利的医疗保健系统组织在短时间内管理急剧增加的患者数量方面感到困惑[1，2]。冠状病毒病2019(新冠肺炎)可能会引起间质性肺炎和呼吸窘迫综合征，这可能会导致多器官衰竭[3]。在新冠肺炎肺炎的急性期，患者可能需要无创机械通气、持续正压通气或无创静脉注射，或气管内插管[4]。此外，新冠肺炎似乎影响到多个器官，如心脏和肾脏，还会导致血管损伤，促进血栓形成[5]。急性期后，应进行特定的康复，以实现呼吸改善、功能和认知恢复，减少残疾，并提高生活质量[1]。自我们在圣拉斐尔科学研究所(意大利米兰)的新冠肺炎康复单元于2020年3月底(约1个月前)开业以来，已有50名患者入院。入院标准是鼻咽拭子试验阳性和功能独立性测量(FIM)值显示对运动或呼吸功能的依赖性。我们队列中的平均FIM值为76.6。在康复期间，患者的吞咽功能和营养状况由一个多学科团队[1]照顾。在我们的队列中，超过90%的新冠肺炎患者表现出不同程度的吞咽困难，需要改变饮食的稠度或鼻饲。以前的通讯报告说，经口气管插管后吞咽困难的发生率约为50%。我们的人口反映了这个比率[6]。这些发现表明，营养支持和吞咽训练对于这类特殊类型的患者的功能恢复至关重要。此外，充足的营养状态可以在出现病理情况时具有更好的弹性，例如新冠肺炎感染。根据营养不良通用筛查工具(MASH)，我们发现我国45%的人口(50例)存在营养不良的高风险，而26%的患者显示出中等风险。最近，据报道，低前白蛋白水平与急性呼吸窘迫综合征的发生率密切相关；因此，较差的营养状况代表了SARS-CoV-2的负面预后因素[3]。SARS-CoV-2呼吸综合征常常伴随着长时间的制动，这会导致肌肉功能的下降，直到骨骼减少。骨质疏松症与营养不良、残疾以及更普遍的生活质量恶化的风险增加有关[1]。新冠肺炎患者营养不良的风险与慢性疾病和恶心、腹泻、食欲不振引起的食物摄入量减少有关。在新冠肺炎患者中观察到的最常见的慢性疾病是糖尿病、慢性阻塞性肺疾病、肾功能不全、心血管疾病和痴呆。此外，众所周知，高龄与营养不良的风险密切相关：根据意大利卫生理事会最新公布的意大利感染数据，约40%的新冠肺炎感染者年龄在70岁以上。最近发表了一些关于新冠肺炎患者营养方面的临床通讯。辛托尼等人。支持个性化膳食供应方案和口服食品补充剂相结合，以满足那些可以口服的患者由新冠肺炎诱导的高能量和蛋白质需求。对于那些无法进食的人，高蛋白和肠内/肠外营养(PN)
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has confounded the healthcare system organizations, especially in Italy, in the management of a dramatically increasing number of patients over a short period of time [1, 2]. Coronavirus disease 2019 (COVID-19) may cause interstitial pneumonia and respiratory distress syndrome, which can lead to multi-organ failure [3]. During the acute phase of COVID-19 pneumonia, patients may need noninvasive ventilation, CPAP or NIV, or endotracheal intubation [4]. Furthermore, COVID-19 seems to affect multiple organs, such as heart and kidney, and also to cause vascular damages facilitating thrombosis [5]. After the acute phase, specific rehabilitation should be performed to achieve respiratory improvement, functional and cognitive recovery, to decrease disability, and to improve quality of life [1]. Since the opening of our COVID-19 Rehabilitation Unit at the San Raffaele Scientific Institute (Milan, Italy) at the end of March 2020 (about 1 month ago), 50 patients have been admitted. Criteria for admission were positive nasopharyngeal swab test and functional independence measure (FIM) values showing dependence for motor or respiratory functions. The average FIM value in our cohort was 76.6. During the rehabilitation period, the swallowing function and the nutritional status of patients have been taken care of by a multidisciplinary team [1]. More than 90% of COVID-19 patients in our cohort showed some degree of dysphagia, with the need of a modified diet’s consistency or nasogastric feeding. Previous communications reported a rate of dysphagia after orotracheal intubation of about 50%. Our population reflects this rate [6]. These findings suggest that nutritional support and swallowing training are pivotal for the functional recovery of this particular type of patients. Moreover, adequate nutritional status allows for better resilience in the presence of pathological conditions, such as in the case of COVID-19 infection. Based upon the Malnutrition Universal Screen Tool (MUST), we found a high risk of malnutrition in 45% of our population (50 cases), whereas 26% of patients showed a moderate risk. Recently, it has been reported that low prealbumin levels are strongly related to the rate of acute respiratory distress syndrome; therefore a worse nutritional status represents a negative prognostic factor for SARS-CoV-2 [3]. Respiratory syndrome of SARS-CoV-2 is often accompanied by prolonged immobilization, which can cause reduction of muscle functions until sarcopenia. Sarcopenia is related to an increased risk of malnutrition, disability, and more generally a worsening of the quality of life [1]. The risk of malnutrition of COVID-19 patients is related to chronic pathologies and the reduction of food intake caused by nausea, diarrhea, and the loss of appetite. The most common chronic conditions observed in COVID-19 patients are diabetes, chronic obstructive pulmonary disease, renal insufficiency, cardiovascular diseases, and dementia. Moreover, it is also well-known that advanced age is deeply related to the risk of malnutrition: according to the last published data by Italian Health Council regarding infections in Italy, about 40% of those infected by COVID-19 are over 70 years old or more. Some recent clinical communications have been published on the nutritional aspects of COVID-19 patients. Cintoni et al. supported a personalized meal supply protocol combined with oral food supplements to adequate the high energetic and proteic requirements induced by COVID-19, in those patients that can be fed orally. For those unable to eat, high proteins and enteral/parenteral nutrition (PN)