A Comparison Between Ventilation Modes: How Does Activity Level Affect Energy Expenditure Estimates?

Abstract

Background: An appropriate diet is essential to avoid complications of overfeeding or underfeeding in mechanically ventilated intensive care unit (ICU) patients. The paucity of consistent comparative data on energy expenditure for each ventilation mode complicates diet prescription. This study evaluates caloric requirements by comparing estimated and measured energy expenditure values for 2 ventilation modes. Methods: The energy expenditure of 100 ICU patients on assisted or controlled mechanical ventilation was measured by indirect calorimetry for 20 minutes. Values were calculated for a 24-hour period and compared with Harris-Benedict estimates multiplied by an injury factor and either multiplied or not by a 10% activity factor. Results: The mean Harris-Benedict estimate was 1858.87± 488.67 kcal/24 h when multiplied by an injury factor and a 10% activity factor. The mean energy expenditure values measured by indirect calorimetry were 1712.76 ± 491.95 kcal/24 h for controlled and 1867.33± 542.67 kcal/24 h for assisted ventilation. The mean total energy expenditure for assisted ventilation was 10.71% greater than the mean for controlled ventilation (P < .001). For controlled ventilation, Harris-Benedict results overestimated indirect calorimetry values by 141.10± 10 kcal/24 h (8.2%, P = .012) when multiplied by injury and activity factors, and underestimated values by 44.28 ± 28 kcal/24 h (2.6%, P = .399) when the equation was calculated without the activity factor. For assisted ventilation, Harris-Benedict results underestimated indirect calorimetry values by 198.84 ± 84 kcal/24 h (10.7%, P = .001) when not multiplied by the activity factor and by 13.46 kcal/24 h (0.75%) when the activity factor was used, but differences were not statistically significant (P = .829). Conclusions: Results suggest that a 10% activity factor should be adopted only for assisted ventilation because multiplication by an activity factor may lead to overfeeding of patients on controlled ventilation.

Energy expenditure of mechanically ventilated patients on assisted or controlled ventilation was measured and correlated with Harris-Benedict estimates, which were either multiplied by an activity factor or not, to evaluate and compare calorie requirements.

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References

Askanazi J, Rosembaum SH, Hyman AI, Silverberg PA, Milic-Emily J, Kinney JM. Respiratory changes induced by the large glucose loads of total parenteral nutrition. JAMA.1980 ;243:1444 -1447.

Covelli HD, Black JW, Olesson MS, Beekman JF. Respiratory failure precipitated by high carbohydrate loads. Ann Intern Med.1981 ;95:579 -581.

Ireton-Jones CS, Borman KR, Turner WW. Nutrition considerations in the management of ventilator-dependent patients. Nutr Clin Pract. 1993;8:60 -64.

Christman JW, McCain RW. A sensible approach to the nutritional support of mechanically ventilated critically ill patients. Intensive Care Med. 1993;19:129 -133.

Cheng CH, Chen CH, Wong Y, Lee BS, Kan MN, Huang YC. Measured versus estimated energy expenditure in mechanically ventilated critically ill patients. Clin Nutr.2002 ;21:165 -172.

Benotti PN, Bistrian B. Metabolic and nutritional aspects of weaning from mechanical ventilated. Crit Care Med.1989 ;17:181 .

Krishnan JA, Parce PB, Martinez A, Diette GB, Brower RC. Caloric intake in medical icu patients: consistency of care with guidelines and relationship to clinical outcomes. Chest.2003 ;124:297 -305.

Mullen JL. Indirect calorimetry in critical care. Proc Nutr Soc. 1991;50:239 -244.

Hernandez Chávez A, Corona Jiménez F, Gutiérrez de La Rosa JL, Hernandez Jiménez A, Cumplido Hernandez G, López Guillén P. El gasto energético en reposo, medido contra estimado, em pacientes críticamente enfermos. Gac Méd Méx. 1994;131:283 -288.

10.

Cunningham K, Aeberhardt LE, Wiggs BR, Phang PT. Appropriate interpretation of indirect calorimetry for determining energy expenditure of patients in intensive care units. Am J Surg.1994 ;167:547 -549.

11.

Ward ME, Corbeil C, Gibbons W, Newman S, Macklem P. Optimization of respiratory muscle relaxation during mechanical ventilation.Anesthesiology . 1988;69:29 -35.

12.

Marini JJ. Mechanical ventilation: taking the work out of breathing? Respir Care.1986 ;31:696 -702.

13.

Cox D, Tinloi SF, Farrimond JG. Investigation of the spontaneous modes of breathing of different ventilators. Intensive Care Med. 1988;14:532 -537.

14.

Capps JS, Ritz R, Pierson DJ. An evaluation in four ventilators of characteristics that affect work of breathing. Respir Care.1987 ;32:1017 -1024.

15.

Harris JA, Benedict FG. A Biometric Study of Basal Metabolism in Man. Publication 279. Washington, DC: Carnegie Institute of Washington; 1919.

16.

Detsky AS, McLaughlin JR, Baker JP, et al. What is subjective global assessment of nutritional status? JPEN J Parenter Enteral Nutr. 1987;11:8 -13.

17.

Lohman TG, Rocha AF, Martorell R. Anthropometric Standardization Reference Manual. Abridged ed. Chicago, IL: Human Kinetics Books; 1991.

18.

Petros S, Engelmann L. Validity of an abbreviated indirect calorimetry protocol for measurement of resting energy expenditure in mechanically ventilated and spontaneously breathing critically ill patients.Intensive Care Med .2001 ;27:1164 -1168.

19.

Van Way CW III. Nutrition Secrets. Philadelphia, PA: Hanley & Belfus, Inc; 1999.

20.

Damask MC, Schwarz Y, Weissmann C. Energy measurements and requirements of critically ill patients. Crit Care Clin.1987 ;3:71 -96.

21.

Basile-Filho A, Martins M, Antoniazzi PC, Marchini JS. Indirect calorimetry in the critically ill patient. RBTI. 2003 ;15:29 -33.

22.

Diener JRC. Calorimetria Indireta. Rev Assoc Med Bras. 1997;43:245 -253.

23.

Martins MA, Campos Filho WO, Viana JM, Nicolini EA, Campos AD, Basile-Filho A. Comparative analysis of cardiac output (CO) calculated by Fick's method and measured by indirect calorimetry in septic patients.RBTI . 2003;15:5 -14.

24.

Burzstein S, Saphar P, Singer P, Elwyn DH. A mathematical analysis of indirect calorimetry measurements in cutely ill patients. Am J Clin Nutr. 1989;50:227 -230.

25.

Takala J, Merilánen P. Handbook of Gas Exchange and Indirect Calorimetry. Datex-Ohmeda. Doc. 876710. Kuopio, Finland: Datex-Ohmeda Division, Instrumentarium Corp; 1990.

26.

Swinamer DL, Grace MG, Hamilton SM, Jones RL, Roberts P, King G. Predictive equation for assessing energy metabolism in mechanically ventilated critically ill patients. Crit Care Med.1990 ;18:657 .

27.

Brandi LS, Bertolini R, Calafà M. Indirect calorimetry in critically ill patients: clinical applications and practical advice.Nutrition . 1997;13:349 -358.

28.

Basile-Filho A, Martins MA, Batiston MT, Vinha PP. Energy expenditure in septic patients: correlation between indirect calorimetry and predictive equations derivated from hemodynamic data. RBTI.2003 ;15:101 -107.

29.

Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system. Crit Care Med.1985 ;13:818 -829.

30.

Grant JP, Custer PB, Thurlow J. Current techniques of nutritional assessment. Symposium on Surgical Nutrition. Surg Clin North Am. 1981;61:437 -463.

31.

Baker JP, Detsky AS, Wessom DE, Wolman SL, Stewart S, Whitewell J. Nutritional assessment. N Engl J Med.1982 ;306:969 -972.

32.

Vieira SRR, Plotnik R, Fialkow L. Monitorização da Mecânica Respiratória Durante a Ventilação Mecânica In: Carvalho CRR, ed. Ventilação Mecânica. Vol 1. Básico. São Paulo, Brazil: Editora Atheneu; 2000:215 -252.

33.

Tobin MJ, van de Graeff WB. Monitoring of lung mechanics and the work of breathing. In: Tobin MJ, ed. Principles and Practice of Mechanical Ventilation. New York, NY: McGraw-Hill; 1994:967 -1003.

34.

Amato MBP, Barbas CSV. Trabalho respiratório. In:Princípios da Ventilação Mecânica. Barcelona, Spain: Permanyer Publications; 1998:55 -74.

35.

Annat G, Viale JP. Measuring the breathing workload in mechanically ventilated patients. Intensive Care Med.1990 ;16:418 -421.

36.

van Lanschot JJB, Feenstra BWA, Vermeij CG, Bruining HA. Calculation versus measurement of total energy expenditure. Crit Care Med. 1986;14:981 -985.

37.

Weissman C, Kemper M, Hyman AI. Variation in the resting metabolic rate of mechanically ventilated critically ill patients. Anesth Analg. 1989;68:457 -461.

38.

Weissman C, Kemper M, Elwyn DH, Askanazi J, Hyman AI, Kinney JM. The energy expenditure of the mechanically ventilated critically ill patient.Chest . 1986;89:254 -259.

39.

Faisy C, Guerrot E, Diehl J-L, Labrousse J, Fagon JY. Assessment of resting energy expenditure in mechanically ventilated patients. Am J Clin Nutr. 2003;78:241 -249.

40.

Colleto FA. Avaliação do gasto energético obtido pela calorimetria indireta e pela equação de Harris-Benedict no paciente em estado grave. Ribeirão Preto: FMRP; 2002: 90. Dissertação (Mestrado em Clínica Cirúrgica), Faculdade de Medicina de Ribeirão Preto. DatDef 03.12.2003.

41.

Long CL, Schaffel N, Geiger JW, Schiller WR, Blakemore WS. Metabolic response to injury and illness: estimation of energy and protein needs from indirect calorimetry and nitrogen balance. JPEN J Parenter Enteral Nutr. 1979;3:452 -456.

42.

Singer JA, Singer P. Measured resting energy expenditure in the normal, overweight and obese Israeli population. Rev Bras de Nutr Clín. 2005;20:6 -8.

43.

Nonino CB. Calorimetria indireta x Harris-Benedict: determinação, validação e comparação para cálculo da taxa metabólica de repouso em obesos grau III. Ribeirão Preto FMRP; 2002. Dissertação (Mestrado em Clínica Médica), Faculdade de Medicina de Ribeirão Preto. DatDef. 22/03/2002.

44.

Ribeiro PC. Nutritional therapy in sepsis. RBTI.2004 ;16:175 -178.