Respiratory-rate Oxygenation index for Predicting Noninvasive Ventilation Associated With High-flow Nasal Cannula Failure in Acute Respiratory Failure Due to SARS-CoV-2
Restricted accessResearch articleFirst published online February, 2025
Respiratory-rate Oxygenation index for Predicting Noninvasive Ventilation Associated With High-flow Nasal Cannula Failure in Acute Respiratory Failure Due to SARS-CoV-2
The respiratory rate-oxygenation (ROX) index is used to predict high-flow nasal cannula (HFNC) success in acute respiratory failure, including in Coronavirus disease 2019 (COVID-19) patients. However, no study has described its performance to predict failure of alternating sessions of noninvasive ventilation (NIV) and HFNC in severe COVID-19 patients.
Material and methods
We conducted a monocentric retrospective cohort study. COVID-19 patients admitted in the intensive care unit (ICU) for acute respiratory failure were treated by alternating sessions of HFNC and NIV. The primary endpoint was the ability for ROX index at 2 hours (h) of NIV initiation to predict HFNC/NIV failure defined by orotracheal intubation (OTI) within 7 days after noninvasive support initiation.
Results
One hundred and five patients were included in analysis, of which 47% (n = 49) required OTI by day seven. ROX index values were significantly lower in intubated group at all time points but 24 h. In multivariate analysis, a ROX index at 2 h < 4.88 was associated with a higher risk of HFNC/NIV failure (Hazard Ratio 1.90 [95% Confidence Interval 1.03-3.51], p = 0.039). The area under the receiver operating characteristic curve for ROX index at 2 h was 0.702 [0.608-0.790]. Optimal cut-off value was 5.22. Sensitivity and specificity for predicting intubation with this threshold were 71.4% and 63.3%, respectively.
Conclusions
In our study, the ROX index had a good predictive power for alternating sessions of HFNC and NIV failure in patients with acute respiratory failure due to SARS-CoV-2.
ZhuJJiPPangJ, et al.Clinical characteristics of 3062 COVID-19 patients: a meta-analysis. J Med Virol. 2020;92(10):1902-1914. doi:https://doi.org/10.1002/jmv.25884
3.
AlhazzaniWMøllerMHArabiYM, et al.Surviving sepsis campaign: guidelines on the management of critically ill adults with coronavirus disease 2019 (COVID-19). Intensive Care Med. 2020;46(5):854-887. doi:https://doi.org/10.1007/s00134-020-06022-5
4.
RochwergBGrantonDWangDX, et al.High flow nasal cannula compared with conventional oxygen therapy for acute hypoxemic respiratory failure: a systematic review and meta-analysis. Intensive Care Med. 2019;45(5):563-572. doi:https://doi.org/10.1007/s00134-019-05590-5
5.
Ospina-TascónGACalderón-TapiaLEGarcíaAF, et al.Effect of high-flow oxygen therapy vs conventional oxygen therapy on invasive mechanical ventilation and clinical recovery in patients with severe COVID-19: a randomized clinical trial. JAMA. 2021;326(21):2161. doi:https://doi.org/10.1001/jama.2021.20714
6.
FratJPQuenotJPBadieJ, et al.Effect of high-flow nasal cannula oxygen vs standard oxygen therapy on mortality in patients with respiratory failure due to COVID-19: the SOHO-COVID randomized clinical trial. JAMA. 2022;328(12):1212. doi:https://doi.org/10.1001/jama.2022.15613
7.
PerkinsGDJiCConnollyBA, et al.Effect of noninvasive respiratory strategies on intubation or mortality among patients with acute hypoxemic respiratory failure and COVID-19: the RECOVERY-RS randomized clinical trial. JAMA. 2022;327(6):546. doi:https://doi.org/10.1001/jama.2022.0028
8.
GriecoDLMengaLSCesaranoM, et al.Effect of helmet noninvasive ventilation vs high-flow nasal oxygen on days free of respiratory support in patients with COVID-19 and moderate to severe hypoxemic respiratory failure: the HENIVOT randomized clinical trial. JAMA. 2021;325(17):1731. doi:https://doi.org/10.1001/jama.2021.4682
9.
ArabiYMAldekhylSAl QahtaniS, et al.Effect of helmet noninvasive ventilation vs usual respiratory support on mortality among patients with acute hypoxemic respiratory failure due to COVID-19: the HELMET-COVID randomized clinical trial. JAMA. 2022;328(11):1063. doi:https://doi.org/10.1001/jama.2022.15599
10.
World Health Organization. Management of critical COVID-19 Advanced non-invasive respiratory support: high-flow nasal oxygen and non-invasive ventilation- Part 1. World Health Organization; 2022. Available at: https://www.who.int/publications/m/item/management-of-critical--covid-19-advanced-non-invasive-respiratory-support---high-flow-nasal-oxygen-and-non-invasive-ventilation
11.
XixiNAKremmydasPXourgiaE, et al.Association between timing of intubation and clinical outcomes of critically ill patients: a meta-analysis. J Crit Care.2022;71:154062. doi:https://doi.org/10.1016/j.jcrc.2022.154062
12.
COVID-ICU group, for the REVA network, COVID-ICU investigators, SchmidtMDemouleA, et al.Benefits and risks of noninvasive oxygenation strategy in COVID-19: a multicenter, prospective cohort study (COVID-ICU) in 137 hospitals. Crit Care. 2021;25(1):421. doi:https://doi.org/10.1186/s13054-021-03784-2
13.
BattagliniDRobbaCBallL, et al.Noninvasive respiratory support and patient self-inflicted lung injury in COVID-19: a narrative review. Br J Anaesth.2021;127(3):353-364. doi:https://doi.org/10.1016/j.bja.2021.05.024
14.
RocaOMessikaJCaraltB, et al.Predicting success of high-flow nasal cannula in pneumonia patients with hypoxemic respiratory failure: the utility of the ROX index. J Crit Care.2016;35:200-205. doi:https://doi.org/10.1016/j.jcrc.2016.05.022
15.
RocaOCaraltBMessikaJ, et al.An index combining respiratory rate and oxygenation to predict outcome of nasal high-flow therapy. Am J Respir Crit Care Med. 2019;199(11):1368-1376. doi:https://doi.org/10.1164/rccm.201803-0589OC
16.
JunhaiZJingYBeibeiC, et al.The value of ROX index in predicting the outcome of high flow nasal cannula: a systematic review and meta-analysis. Respir Res. 2022;23(1):33. doi:https://doi.org/10.1186/s12931-022-01951-9
17.
PrakashJBhattacharyaPKYadavAK, et al.ROX index as a good predictor of high flow nasal cannula failure in COVID-19 patients with acute hypoxemic respiratory failure: a systematic review and meta-analysis. J Crit Care.2021;66:102-108. doi:https://doi.org/10.1016/j.jcrc.2021.08.012
18.
DuanJYangJJiangL, et al.Prediction of noninvasive ventilation failure using the ROX index in patients with de novo acute respiratory failure. Ann Intensive Care. 2022;12(1):110. doi:https://doi.org/10.1186/s13613-022-01085-7
19.
InnocentiFLazzariCPaolucciE, et al.Role of prognostic scores in predicting in-hospital mortality and failure of non-invasive ventilation in adults with COVID-19. Intern Emerg Med. 2022;17(8):2367-2377. doi:https://doi.org/10.1007/s11739-022-03058-x
20.
DuanJHanXBaiL, et al.Assessment of heart rate, acidosis, consciousness, oxygenation, and respiratory rate to predict noninvasive ventilation failure in hypoxemic patients. Intensive Care Med. 2017;43(2):192-199. doi:https://doi.org/10.1007/s00134-016-4601-3
21.
CarrilloALopezACarrilloL, et al.Validity of a clinical scale in predicting the failure of non-invasive ventilation in hypoxemic patients. J Crit Care.2020;60:152-158. doi:https://doi.org/10.1016/j.jcrc.2020.08.008
22.
MannarinoMRBianconiVCosentiniE, et al.The HACOR score predicts worse in-hospital prognosis in patients hospitalized with COVID-19. JCM. 2022;11(12):3509. doi:https://doi.org/10.3390/jcm11123509
23.
GuiaMFBoléo-ToméJPImitazioneP, et al.Usefulness of the HACOR score in predicting success of CPAP in COVID-19-related hypoxemia. Respir Med.2021;187:106550. doi:https://doi.org/10.1016/j.rmed.2021.106550
24.
SantusPPiniSAmatiF, et al.Predictors of helmet CPAP failure in COVID-19 pneumonia: a prospective, multicenter, and observational cohort study. Can Respir J.2022;2022:1499690. doi:https://doi.org/10.1155/2022/1499690
25.
VincentJLMorenoRTakalaJ, et al.The SOFA (sepsis-related organ failure assessment) score to describe organ dysfunction/failure: on behalf of the working group on sepsis-related problems of the European Society of Intensive Care Medicine (see contributors to the project in the appendix). Intensive Care Med. 1996;22(7):707-710. doi:https://doi.org/10.1007/BF01709751
26.
KnausWADraperEAWagnerDP, et al.APACHE II: a severity of disease classification system. Crit Care Med. 1985;13(10):818-829.
CannessonMLe ManachYHoferCK, et al.Assessing the diagnostic accuracy of pulse pressure variations for the prediction of fluid responsiveness. Anesthesiology. 2011;115(2):231-241. doi:https://doi.org/10.1097/ALN.0b013e318225b80a
ChandelAPatoliaSBrownAW, et al.High-flow nasal cannula therapy in COVID-19: using the ROX index to predict success. Respir Care. 2021;66(6):909-919. doi:https://doi.org/10.4187/respcare.08631
31.
FerrerMEsquinasALeonM, et al.Noninvasive ventilation in severe hypoxemic respiratory failure: a randomized clinical trial. Am J Respir Crit Care Med. 2003;168(12):1438-1444. doi:https://doi.org/10.1164/rccm.200301-072OC
32.
PoopipatpabSNuchpramoolPPhairatwetP, et al.The use of respiratory rate-oxygenation index to predict failure of high-flow nasal cannula in patients with coronavirus disease 2019-associated acute respiratory distress syndrome: a retrospective study. PLoS ONE. 2023;18(6):e0287432. doi:https://doi.org/10.1371/journal.pone.0287432
33.
ValenciaCFLuceroODCastroOC, et al.Comparison of ROX and HACOR scales to predict high-flow nasal cannula failure in patients with SARS-CoV-2 pneumonia. Sci Rep. 2021;11(1):22559. doi:https://doi.org/10.1038/s41598-021-02078-5
34.
KimJHBaekARLeeSI, et al.ROX index and SpO2/FiO2 ratio for predicting high-flow nasal cannula failure in hypoxemic COVID-19 patients: a multicenter retrospective study. PLoS ONE. 2022;17(5):e0268431. doi:https://doi.org/10.1371/journal.pone.0268431
35.
BrownSMGrissomCKMossM, et al.Nonlinear imputation of PaO2/FiO2 from SpO2/FiO2 among patients with acute respiratory distress syndrome. Chest. 2016;150(2):307-313. doi:https://doi.org/10.1016/j.chest.2016.01.003
36.
KarimHMREsquinasAM. Success or failure of high-flow nasal oxygen therapy: the ROX index is good, but a modified ROX index may be better. Am J Respir Crit Care Med. 2019;200(1):116-117. doi:https://doi.org/10.1164/rccm.201902-0419LE
37.
LiZChenCTanZ, et al.Prediction of high-flow nasal cannula outcomes at the early phase using the modified respiratory rate oxygenation index. BMC Pulm Med. 2022;22(1):227. doi:https://doi.org/10.1186/s12890-022-02017-8
38.
VeraMKattanEBornP, et al.Intubation timing as determinant of outcome in patients with acute respiratory distress syndrome by SARS-CoV-2 infection. J Crit Care.2021;65:164-169. doi:https://doi.org/10.1016/j.jcrc.2021.06.008
39.
PapoutsiEGiannakoulisVGXourgiaE, et al.Effect of timing of intubation on clinical outcomes of critically ill patients with COVID-19: a systematic review and meta-analysis of non-randomized cohort studies. Crit Care. 2021;25(1):121. doi:https://doi.org/10.1186/s13054-021-03540-6
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