Oriol Roca1,2, Berta Caralt1,3, Jonathan Messika4,5,6, Manuel Samper7, Benjamin Sztrymf8,9, Gonzalo Hernández10, Marina García-de-Acilu1, Jean-Pierre Frat11,12,13, Joan R Masclans3,2,7, Jean-Damien Ricard4,5,6. 1. 1 Critical Care Department, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute and. 2. 2 Ciber Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain. 3. 3 Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain. 4. 4 Service de Réanimation Médico-Chirurgicale, Hôpital Louis Mourier, Assistance Publique-Hôpitaux de Paris (AP-HP), Colombes, France. 5. 5 INSERM, Infection Antimicrobials Modelling Evolution (IAME), Unité Mixte de Recherche (UMR) 1137, Paris, France. 6. 6 Université Paris Diderot, IAME, UMR 1137, Sorbonne Paris Cité, Paris, France. 7. 7 Critical Care Department, Hospital del Mar, Mar Research Institute, Barcelona, Spain. 8. 8 Service de Réanimation Polyvalente et Surveillance Continue, Hôpital Antoine Béclère, AP-HP, Clamart, France. 9. 9 INSERM U999: Pulmonary Hypertension, Physiopathologie et Innovation Thérapeutique, Hôpital Marie Lannelongue, Le Plessis Robinson, France. 10. 10 Critical Care Department, Virgen de la Salud University Hospital, Toledo, Spain. 11. 11 Réanimation Médicale, Centre Hospitalier Universitaire de Poitiers, Poitiers, France. 12. 12 Faculté de Médecine et de Pharmacie de Poitiers, Université de Poitiers, Poitiers, France; and. 13. 13 INSERM, Centre d'Investigation Clinique-1402, Equipe 5 Acute Lung Injury and Ventilatory Support, Poitiers, France.
Abstract
Rationale: One important concern during high-flow nasal cannula (HFNC) therapy in patients with acute hypoxemic respiratory failure is to not delay intubation. Objectives: To validate the diagnostic accuracy of an index (termed ROX and defined as the ratio of oxygen saturation as measured by pulse oximetry/FiO2 to respiratory rate) for determining HFNC outcome (need or not for intubation). Methods: This was a 2-year multicenter prospective observational cohort study including patients with pneumonia treated with HFNC. Identification was through Cox proportional hazards modeling of ROX association with HFNC outcome. The most specific cutoff of the ROX index to predict HFNC failure and success was assessed. Measurements and Main Results: Among the 191 patients treated with HFNC in the validation cohort, 68 (35.6%) required intubation. The prediction accuracy of the ROX index increased over time (area under the receiver operating characteristic curve: 2 h, 0.679; 6 h, 0.703; 12 h, 0.759). ROX greater than or equal to 4.88 measured at 2 (hazard ratio, 0.434; 95% confidence interval, 0.264-0.715; P = 0.001), 6 (hazard ratio, 0.304; 95% confidence interval, 0.182-0.509; P < 0.001), or 12 hours (hazard ratio, 0.291; 95% confidence interval, 0.161-0.524; P < 0.001) after HFNC initiation was consistently associated with a lower risk for intubation. A ROX less than 2.85, less than 3.47, and less than 3.85 at 2, 6, and 12 hours of HFNC initiation, respectively, were predictors of HFNC failure. Patients who failed presented a lower increase in the values of the ROX index over the 12 hours. Among components of the index, oxygen saturation as measured by pulse oximetry/FiO2 had a greater weight than respiratory rate. Conclusions: In patients with pneumonia with acute respiratory failure treated with HFNC, ROX is an index that can help identify those patients with low and those with high risk for intubation. Clinical trial registered with www.clinicaltrials.gov (NCT02845128).
Rationale: One important concern during high-flow nasal cannula (HFNC) therapy in patients with acute hypoxemic respiratory failure is to not delay intubation. Objectives: To validate the diagnostic accuracy of an index (termed ROX and defined as the ratio of oxygen saturation as measured by pulse oximetry/FiO2 to respiratory rate) for determining HFNC outcome (need or not for intubation). Methods: This was a 2-year multicenter prospective observational cohort study including patients with pneumonia treated with HFNC. Identification was through Cox proportional hazards modeling of ROX association with HFNC outcome. The most specific cutoff of the ROX index to predict HFNC failure and success was assessed. Measurements and Main Results: Among the 191 patients treated with HFNC in the validation cohort, 68 (35.6%) required intubation. The prediction accuracy of the ROX index increased over time (area under the receiver operating characteristic curve: 2 h, 0.679; 6 h, 0.703; 12 h, 0.759). ROX greater than or equal to 4.88 measured at 2 (hazard ratio, 0.434; 95% confidence interval, 0.264-0.715; P = 0.001), 6 (hazard ratio, 0.304; 95% confidence interval, 0.182-0.509; P < 0.001), or 12 hours (hazard ratio, 0.291; 95% confidence interval, 0.161-0.524; P < 0.001) after HFNC initiation was consistently associated with a lower risk for intubation. A ROX less than 2.85, less than 3.47, and less than 3.85 at 2, 6, and 12 hours of HFNC initiation, respectively, were predictors of HFNC failure. Patients who failed presented a lower increase in the values of the ROX index over the 12 hours. Among components of the index, oxygen saturation as measured by pulse oximetry/FiO2 had a greater weight than respiratory rate. Conclusions: In patients with pneumonia with acute respiratory failure treated with HFNC, ROX is an index that can help identify those patients with low and those with high risk for intubation. Clinical trial registered with www.clinicaltrials.gov (NCT02845128).
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