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We followed with interest the discussion [1, 2] fueled by the study of Stapel et al. [3] who reported fairly accurate assessment of energy expenditure (EE) in critically ill patients based on ventilator-derived carbon dioxide production (VCO2). The proposed technique is elegant and valid but has inherent limitations. It is applicable in patients who are in one way or another ventilator-dependent but not in spontaneously breathing yet oxygen-dependent subjects. We concur that VO2 is the most relevant variable for EE measurement. However, the most accurate and precise estimation of EE in a critically ill population can only be obtained by sampling of inspired and expired oxygen/carbon dioxide concentrations and measuring expired gas flow. This is the core task of indirect calorimetry [4].

VCO2 calorimetry: stop tossing stones, it’s time for building!