Nutritional manipulation of carbon dioxide production

Again, the available enteral supplements

properties Jevity Jevity HiCal Nepro Pulmocare Promote
Calories per ml 1.06 1.5 2.0 1.5 1.0
% calories from carbohydrate 54.3% 53.6% 43% 28.2% 50%
% calories from protein 16.7% 17% 14% 16.7% 25%
% calories from fat 29% 29.4 43% 55.1% 25%
calorie:nitrogen ratio 150:1 147:1 179:1 125:1 100:1
Osmolality 300 mOsm/Kg 525 mOsm/Kg 665 mOsm/Kg 475 mOsm/Kg 380 mOsm/Kg
Volume to supplement the recommended daily intake of vitamins, mineral and protein 1316 ml 1176 ml 1200 ml 1000 ml 1100 ml
Carbohydrate content (per ml) 0.140 g 0.201 g 0.206 g 0.106 g 0.124 g
Protein content (per ml) 0.040 g 0.064 g 0.070 g 0.063 g 0.063 g
Fat content (per ml) 0.035 g 0.049 g 0.096 g 0.093 g 0.028 g
Water content (per ml) 0.83 g 0.76 g 0.70 g 0.79 g 0.83 g

It has been held as gospel truth that high-fat, low-carb supplements decrease CO2 production in the CO2-retaining population of respiratory failure patients. This practice is supported by heterogenous studies with small effect sizes. The one specific study which is frequently referred to is the al Saady paper from 1989, which in a cohort of 40 randomised patients found that the high-fat low-carb diet caused a reduction in ventilator days (by 62 hours) and an average decrease in PaCO2 (by 16%). There is also evidence to suggest suggest that there is an increase in CO2 production for patients who are overfed, irrespective of what form the nutrition takes. The Canadians suggest that there is insufficient evidence to make a firm recommendation about this practice. The prevailing opinion is that the use of high-fat diets should be targetted at the population of acute COPD patients who are spontaneously ventilated.

Is there any scientific foundation to the assertion that high fat diets result in decreased CO2 production?

Yes, there is sound theory underpinning this. The respiratory quotient for pure carbohydrate oxidation is 1.0 (that is, the ratio of CO2 production to O2 consumption). During the complete oxidation of a 6-carbon glucose molecule (C6H12O12), 6 molecules of CO2 and 6 molecules of H2O are produced. For fat, the respiratory quotient is about 0.7. A fatty acid contains less oxygen than glucose, and thus consumes more exogenous oxygen in the course of its metabolism. Thus, during the complete metabolism of the 16-carbon palmitic acid (C16H32O2) one ends up needing 23 molecules of oxygen, giving a respiratory quotient of 0.696 (16 divided by 23). Notice how the amount of CO2 produced is the same. It doesn't matter what is burned- there is one CO2 molecule produced per every carbon atom metabolised.

Thus, if one were to feed their patient fewer carbon atoms, one would expect less CO2 production.

Now, we know the fatty acid would produce 7 ATP per carbon atom, and glucose produces only 5 ATP per carbon. Thus one needs to give their patient less fat than glucose to achieve the same caloric goal. Therein lies the lure of fat. Pulmocare which is 55% fat should be metabolised into fewer CO2 atoms while still supplying adequate nutrition.

But, does this actually happen?

Is there experimental evidence to support the theory that high fat diets result in decreased CO2 production?

In 1992, a group from the Osler Chest Unit in Oxford published their findings in Thorax. They tortured ten COPD patients with Pulmocare, Ensure Plus and artificially sweetened water. This group achieved a small change in blood gases (PaCO2 increased by 1.3%, with a peak at 30 minutes post ingestion), but they also discovered that exercise tolerance was significantly impaired after a high-carbohydrate meal. The magnitude of the rise in PaCO2 was attributed to the increased respiratory rate.

Similarly, a study from Beijing examined the effects of high-fat and high-carb diets on 60 malnourished COPD patients, and reached an improvement in various pulmonary endpoints in the fatty-diet group (after 3 weeks of such a diet).

Indeed, such is the experimental evidence that the Chest systematic review of nutrition in stable COPD was forced to conclude that "those with marginal ventilatory reserve might benefit from a dietary regimen in which a high percentage of calories are supplied by fat."

But of course, these were all studies and guidelines to direct treatment of ambulant stable COPD patients. What happens in the ICU?

Does the use of Pulmocare actually improve outcomes for a ventilated COPD patient in the ICU?

The already-mentioned al Saady paper is one of two papers specifically dealing with high-fat, low-carb ICU diets. Their outcome was positive.

The other one was the van den Berg trial, which measured PaCo2 and respiratory quotient. They found that the RQ is indeed more favorable among the high-fat group, but there was no change in the PaCO2 during weaning from the ventilator.

The Canadians observed that both papers were inadequately powered, and were forced not to make any firm recommendation. They did however reach an ambiguous and spongy conclusion that "A high fat, low CHO enteral formula may be associated with a reduction in ventilated days in medical ICU patients with respiratory failure".

We refer to our founding fathers. What does The Manual say? Naughton and Tuxen's chapter on acute respiratory failure in COPD (Ch 26, pp. 343-354) notes briefly that in spontaneously ventilated patients with COPD, a high-fat low-carb diet is preferred; however their emphasis was on correcting malnutrition.

Their recommendation does not have a reference, and so a cornered exam candidate cannot refer to any specific paper as the source of this wisdom.


al Saady NM, Blackmore CM, Bennett ED. High fat, low carbohydrate, enteral feeding lowers PaCO2 and reduces the period of ventilation in artificially ventilated patients. Intensive Care Med 1989;15:290-5.B

S S Talpers; D J Romberger; S B Bunce; S K Pingleton Nutritionally associated increased carbon dioxide production. Excess total calories vs high proportion of carbohydrate calories. CHEST.1992;102(2):551-555.

Cai B, Zhu Y, Ma Y, Xu Z, Zao Y, Wang J, Lin Y, Comer GM Effect of supplementing a high-fat, low-carbohydrate enteral formula in COPD patients. .Nutrition. 2003 Mar;19(3):229-32.

Efthimiou J, Mounsey PJ, Benson DN, Madgwick R, Coles SJ, Benson MK. Effect of carbohydrate rich versus fat rich loads on gas exchange and walking performance in patients with chronic obstructive lung disease. Thorax. 1992 Jun;47(6):451-6.

Ferreira I, Brooks D, Lacasse Y, Goldstein R .Nutritional intervention in COPD: a systematic overview.Chest. 2001 Feb;119(2):353-63.

Van den Berg B, Bogaard JM, Hop WC. High fat, low carbohydrate, enteral feeding in patients weaning from the ventilator. Intensive Care Med. 1994 Aug; 20(7): 470-5