ESPEN Guidelines on Parenteral Nutrition: On Cardiology and Pneumology

Nutritional support is becoming a mainstay of the comprehensive therapeutic approach to patients with chronic diseases. Chronic heart failure (CHF) and chronic obstructive pulmonary disease (COPD) are frequently associated with the progressive development of malnutrition, due to reduced energy intake, increased energy expenditure and impaired anabolism. Malnutrition and eventually cachexia have been shown to have a negative influence on the clinical course of CHF and COPD, and to impinge on patients' quality of life. Nutritional support in these patients should be therefore considered, particularly to prevent progressive weight loss, since restoration of lean and fat body mass may not be achievable. In CHF and COPD patients, the gastrointestinal tract is normally accessible and functioning. Although recent reports suggest that heart failure is associated with modifications of intestinal morphology, permeability and absorption, the clinical relevance of these are still not clear. Oral supplementation and enteral nutrition should represent the first choices when cardiopulmonary patients need nutritional support, particularly given the potential complications and economic burden of parenteral nutrition. This appropriately preferential enteral approach partly explains the lack of robust clinical trials of the role of parenteral nutrition in CHF and COPD patients. Based on the available evidence collected via PubMed, Medline, and SCOPUS searches, it is recommended that parenteral nutrition is reserved for those patients in whom malabsorption has been documented and in those in whom enteral nutrition has failed.

Summary of statements: Parenteral Nutrition in Cardiology
Subject	Recommendations	Grade	Number
Background	The prevalence of cardiac cachexia, defined from weight loss of at least 6% in 6 months, has been estimated at about 12–15% in patients in New York Heart Association (NYHA) classes II–IV. The incidence of weight loss >6% in CHF patients with NYHA class III/IV is approximately 10% per year. CHF affects nutritional state, energy and substrate metabolism.	B	1.1
	The mortality in CHF patients with cardiac cachexia is 2–3 times higher than in non-cachectic CHF patients.	B	1.2
	Although there is limited evidence that gut function is impaired in CHF, decreased cardiac function can reduce bowel perfusion and lead to bowel wall oedema, resulting in malabsorption.	B	1.3
Indications	Although there is no evidence available from well-designed studies, PN is recommended to stop or reverse weight loss in patients with evidence of malabsorption, on the basis that it improves outcome in other similar conditions and there is a plausible physiological argument for it.	C	1.4
	Currently there is no indication for PN in the prophylaxis of cardiac cachexia. Further studies are needed to assess the impact of the parenteral administration of specific substrates on cardiac function.	C	1.5
Contra-indications	There are no specific contraindications to PN in CHF patients. However, considering that cardiac function is decreased and water retention is frequently found in CHF patients, it is recommended that PN should be avoided, other than in patients with evidence of malabsorption in whom enteral nutrition has been shown, or is strongly expected, to be ineffective.	B	1.6
Implementation	When feeding CHF patients, either enterally or parenterally, fluid overload must be avoided.	C	1.6
Summary of statements: Parenteral Nutrition in Respiratory Medicine
Subject	Recommendations	Grade	Number
Background	Between 25% and 40% of patients with advanced COPD are malnourished.	B	2.1
	Being underweight and having low fat-free mass are independently associated with a poor prognosis in patients with chronic respiratory insufficiency, especially in COPD.	B	2.2
Indications	There is no evidence showing that gut function is impaired in COPD patients. Therefore, considering that enteral nutrition is less expensive and associated with fewer and less severe complications than parenteral nutrition, enteral nutrition should represent the first approach to patients with COPD in need of nutritional support.	B	2.3
	There is limited evidence that COPD patients intolerant of EN profit from PN. Small studies do however suggest that, in combination with exercise and anabolic pharmacotherapy, PN has the potential to improve nutritional status and function.	C	2.4
Effect of PN	Loss of body weight is correlated with increased morbidity and mortality. However, due to the lack of studies of its effects, it is not possible to be sure if prognosis is influenced by the provision of PN.	B	2.5
Regimen selection	In patients with stable COPD, glucose-based PN causes an increase in the respiratory CO2 load. PN composition should accordingly be orientated towards lipids as the energy source. There is not sufficient evidence to recommend specific lipid substrates.	B	2.6

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