Acute Crit Care.  2023 Feb;38(1):31-40. 10.4266/acc.2022.01081.

Evaluating the use of the respiratory-rate oxygenation index as a predictor of high-flow nasal cannula oxygen failure in COVID-19

• Weerasuriya S
• Vlachos S
• Bobo A
• Jayaprabhu NB
• Matthews L
• Blackstock AR
• Metaxa V

• KMID: 2540312
• DOI: http://doi.org/10.4266/acc.2022.01081

Abstract

Background
It can be challenging for clinicians to predict which patients with respiratory failure secondary to coronavirus disease 2019 (COVID-19) will fail on high-flow nasal cannula (HFNC) oxygen and require escalation of therapy. This study set out to evaluate the association between the respiratory rate-oxygenation index (ROX) and HFNC failure in such patients and to assess whether ROX trajectory correlates with treatment failure.
Methods
This was a single-centre, retrospective, observational study of patients with COVID-19 requiring HFNC, conducted over a 3-month period. ROX was calculated as “pulse-oximetry oxygen saturation (SpO2) over the fractional inspired oxygen concentration (FiO2)/respiratory rate” for each patient at 2, 4, and 12 hours from starting HFNC. HFNC failure was defined as escalation to continuous positive airway pressure ventilation or invasive mechanical ventilation (IMV). Time-to-event analyses were performed to account for the longitudinal data set and time-dependent variables.
Results
We included 146 patients. Ninety-three (63.7%) experienced HFNC failure, with 53 (36.3%) requiring IMV. Higher ROX values were associated with a lower subhazard of HFNC failure on time-to-HFNC failure analysis (subhazard ratio, 0.29; 95% confidence interval [CI], 0.18–0.46; P<0.001). This remained true after controlling for informative censoring. Median ROX values changed differentially over time, increasing in the HFNC success group (0.06 per hour; 95% CI, 0.05–0.08; P<0.001) but not in the HFNC failure group (0.004 per hour; 95% CI, –0.05 to 0.08; P=0.890).
Conclusions
A higher ROX is associated with a lower risk of HFNC failure. Monitoring ROX trajectory over time may help identify patients at risk of treatment failure. This has potential clinical applications; however, future prospective studies are required.

Keyword

COVID-19; critical care; respiratory failure; respiratory infections

Figure

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  Figure 1. Flowchart of the study cohort. AHRF: acute hypoxemic respiratory failure; COVID-19: coronavirus disease 2019; HFNC: high-flow nasal cannula; CRAP: continuous positive airway pressure; IMV: invasive mechanical ventilation; TEP: treatment escalation plan.

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  Figure 2. Coefficient plot for competing risks semiparametric time-to-high-flow nasal cannula failure analysis. ROX: respiratory rate-oxygenation index; ref: reference; BMI: body mass index; Hx: history; CKD: chronic kidney disease.

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  Figure 3. Cumulative incidence function curve for competing risks semiparametric time-to-high-flow nasal cannula (HFNC) failure analysis. ROX: respiratory rate-oxygenation index.

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  Figure 4. Modelled change over time of respiratory rate-oxygenation index (ROX) values in patients with and without high-flow nasal cannula (HFNC) failure.

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