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Background  In acute respiratory failure, arterial blood gas analysis (ABG) is used to diagnose hypercapnia. Once non-invasive ventilation (NIV) is initiated, ABG should at least be repeated within 1 h to assess PaCO 2  response to treatment in order to help detect NIV failure. The main aim of this study was to assess whether measuring end-tidal CO 2  (EtCO 2 ) with a dedicated naso-buccal sensor during NIV could predict PaCO 2  variation and/or PaCO 2  absolute values. The additional aim was to assess whether active or passive prolonged expiratory maneuvers could improve the agreement between expiratory CO 2  and PaCO 2 .    Methods  This is a prospective study in adult patients suffering from acute hypercapnic respiratory failure (PaCO 2  ≥ 45 mmHg) treated with NIV. EtCO 2  and expiratory CO 2  values during active and passive expiratory maneuvers were measured using a dedicated naso-buccal sensor and compared to concomitant PaCO 2  values. The agreement between two consecutive values of EtCO 2  (delta EtCO 2 ) and two consecutive values of PaCO 2  (delta PaCO 2 ) and between PaCO 2  and concomitant expiratory CO 2  values was assessed using the Bland and Altman method adjusted for the effects of repeated measurements.    Results  Fifty-four datasets from a population of 11 patients (8 COPD and 3 non-COPD patients), were included in the analysis. PaCO 2  values ranged from 39 to 80 mmHg, and EtCO 2  from 12 to 68 mmHg. In the observed agreement between delta EtCO 2  and deltaPaCO 2 , bias was −0.3 mmHg, and limits of agreement were −17.8 and 17.2 mmHg. In agreement between PaCO 2  and EtCO 2 , bias was 14.7 mmHg, and limits of agreement were −6.6 and 36.1 mmHg. Adding active and passive expiration maneuvers did not improve PaCO 2  prediction.    Conclusions  During NIV delivered for acute hypercapnic respiratory failure, measuring EtCO 2  using a dedicating naso-buccal sensor was inaccurate to predict both PaCO 2  and PaCO 2  variations over time. Active and passive expiration maneuvers did not improve PaCO 2  prediction.    Trial registration  ClinicalTrials.gov:  NCT01489150 .

End-tidal carbon dioxide monitoring using a naso-buccal sensor is not appropriate to monitor capnia during non-invasive ventilation