Feasibility of Transcutaneous CO₂-Guided Noninvasive Ventilation Titration on General Medical Floors in the United States

Background: In the United States, many hospitals lack dedicated respiratory care units for patients requiring noninvasive ventilation (NIV), limiting the ability to optimize ventilator settings outside intensive care. Continuous transcutaneous carbon dioxide (TcCO₂) monitoring may offer a practical method to guide NIV titration for hypercapnic respiratory failure in general ward settings. Methods: Using a Sentec TcCO₂ monitor, we performed inpatient NIV titrations on six adults with hypercapnic respiratory failure admitted to medical floors. The sensor was placed on the forehead and heated to 43 °C. Once TcCO₂ stabilized, NIV was initiated and settings were sequentially adjusted to achieve CO₂ reduction while maintaining patient tolerance. Titration continued until TcCO₂ levels plateaued or further pressure increases were not tolerated. Results: Six patients were included: three with COPD, two with amyotrophic lateral sclerosis, and one with heart failure. Five had chronic and one had acute hypercapnic respiratory failure. The median baseline TcCO₂ was 67.0 mmHg (IQR 65.5–77.3) and post-titration TcCO₂ was 56.7 mmHg (IQR 55.0–58.1), representing a 15.4% median reduction. Average titration duration was 37.5 minutes (range 20–55). One patient with advanced COPD was unable to tolerate higher pressures, limiting TcCO₂ improvement. No adverse events occurred. Conclusion: TcCO₂-guided NIV titration is feasible, safe, and effective for optimizing ventilation on general medical wards. This approach may enable more efficient NIV initiation outside the ICU and warrants further study regarding its impact on clinical outcomes such as ICU and hospital length of stay.