Our study shows a small mean difference in the REE derived from the REE-VCO
2 using the derived equation but with low agreement when compared with the gold-standard REE obtained by IC. In addition, we demonstrated the ability of VCO
2 to predict REE based on measurements by the calorimeter and specific regression with very high accuracy (agreement). This represents the “ceiling” of possibility of using VCO
2, but it remains unclear whether this applies to VCO
2 measurements made by the ventilator. Using VCO
2 to estimate energy expenditure is challenged by a medical hazard: the quite unpredicted error as compared with the gold standard. If mean (median) values presented may perhaps be acceptable, the larger scatter is not. Individual subjects may not have an inaccurate evaluation, as clearly shown in Figs.
1 and
2).
Stapel et al. [
5] found that 10% and less than 15% accuracy rates of REE-VCO
2 were 61% and 79%, respectively. Less than 25% and less than 30% inaccuracy rates of REE-VCO
2 were 2% and 0%, respectively. There results were superior to those derived from predictive equations. The differences between their results and those we have shown may be explained by methodological details. First, the VCO
2 measurements in the study by Stapel et al. were obtained as a mean of 24 h and not from a block of 6 h as in our study. In our study, VCO
2 measurements were obtained as a mean of 6 h and compared with a measurement of 20 min using the Deltatrac II instrument. Second, we used a different ventilator (Dräger) from that used in the study by Stapel et al. (Maquet, Rastatt, Germany), and since our study was retrospective, there was no calibration before each measurement. Finally, we did not use an RQ according to nutritional intake but rather three values representing common clinical states, including the RQ of 0.86 used in the study by Stapel et al., which is the most frequent RQ resulting from nutrition. The use of RQ according to nutrition intake has been applied by others in children [
6]. Mehta et al. used an RQ defined by macronutrient administration defined as VCO
2RQmacro (kcal/day) = [3.941(VCO
2/RQmacro) + 1.106(VCO
2)] × 1440. VCO
2-REE was obtained using an RQ of 0.9 using the equation: REE = [3.941 (VCO
2/0.89) + 1.106(VCO
2)] × 1440 = [4.428(VCO
2) + 1.106(VCO
2)] × 1440 = 5.534(VCO
2) × 1440. The authors described a mean bias (limits) for agreement between measured REE and REE-VCO
2 or VCO
2-RQmacro of −0.6 (−14.4 to 13.1) and −2.0 (−42.9 to 38.8), respectively, using REE-VCO
2 in comparison with REE-IC. When patients were classified as hypometabolic or hypermetabolic according to REE-IC divided by the Schoeffield equation, the accuracy, sensitivity, and specificity were 0.86, 1.00, and 0.83 and 0.82, 0.62, and 1.00, respectively. The conclusions of the authors were in favor of using an RQ of 0.89 (the mean of the measurements in their study) and evaluating REE from VCO
2 alone as being an acceptable method. Others [
7] compared REE-IC obtained by a GE module giving continuous VO
2, VCO
2, and REE to an REE-VCO
2 obtained by VCO
2 and a fixed RQ of 0.85. In most patients (89%), accuracy (± 10%) was obtained. However, the authors noted the problems linked to variations in minute volume limiting the validity of the measurements. These variations have been described previously [
11], and a stable ventilation setting has been a condition to validate REE measurements. Finally, Oshima et al. [
8] used another methodology to compare REE-IC with REE-VCO
2. All measurements (VO
2, VCO
2, and REE) were obtained from IC measurements and not from the ventilator. They compared REE-IC with REE-VCO
2 obtained using an RQ of 0.85 or RQ related to nutritional intake. Mean biases (lower, upper 95% confidence intervals) for REE-VCO
2_0.85 and REE-VCO
2_FQ (derived from Food Quotient) were −21 kcal/d (−41, 1) and −48 kcal/d (−67, −28), respectively. The limits of agreement in Bland–Altman plots were (+314, −356) and (+272, −367), respectively. The 5% accuracy rates compared with REE-IC were 46.0% and 46.4%, and 10% accuracy rates were 77.7% and 77.3%, respectively. The authors confirmed the finding from McClave et al. [
12] that RQ is neither a reliable indicator of the feeding status nor strongly associated with non-nutritional factors such as mode of ventilation and acid-base disturbances. RQ based on VCO
2 cannot be as accurate for REE evaluation when compared with VO
2-based equations. The authors concluded that REE-VCO
2 was not accurate enough to be considered an alternative to IC. Using the same methodology, Mouzaki et al. [
12] also evaluated REE-VCO
2 compared with REE-IC in a cardiac pediatric population and reached results similar to those of Oshima et al. Wide limits of agreement and a high percentage error suggested that the REE derived from VCO
2 was inaccurate only when compared with the gold standard. These findings were explained by a large RQ distribution.
Our study has several limitations. It is retrospective and did not take into account sedation, ventilator types, and settings but used a VCO
2 measurement over the 6 h preceding the assessment. The RQ examined used predefined common values and was not obtained according to nutritional intake. Although the sample size was comparable to that of other studies, it was small and single-centered. Finally, there is a limitation in the reliability of some calorimeters when compared with Deltatrac II. Sundström et al. [
13] found higher limits of agreement when comparing Deltatrac II with the Quark device than Stapel et al. found between Datex and the VCO
2 respirator-derived approach. Graf et al. [
14] confirmed these increased limits of agreement when comparing Quark and the CCM device with Deltatrac II. The reliability of the reference calorimetry therefore should be ensured.