The Relationship of Respiratory Rate-Oxygenation (ROX) and Modified ROX Index With High-Flow Nasal Cannula Oxygen Therapy in COVID-19 Patients: An Observational Pilot Study.

Background and aim Respiratory Rate-Oxygenation (ROX) and modified ROX (mROX) indexes have been proposed to detect early high-flow nasal cannula (HFNC) therapy failure. We evaluated the utility and relationship of ROX and mROX indexes in COVID-19 patients started on HFNC oxygen therapy. Methods This pilot study collected data from adult COVID-19 patients requiring HFNC oxygenation from 29 Jan - 29 Jun 2021. The patients were divided into two cohorts based on HFNC therapy success. ROX and mROX were compared using statistical diagnostic testing, including receiver operating characteristics and area under the curve (AUC) using online Epitools (https://epitools.ausvet.com.au/) and MedCalc software (MedCalc Software Ltd, Ostend, Belgium, https://www.medcalc.org/); p<0.05 was considered significant. Results Twenty-seven patients fulfilled the inclusion criteria; 48.15% of therapy failed. The cohort's mean ± standard deviation age was 53.93 ± 10.67 years; 74.1% were male. The accuracy of predicting failure for mean ROX versus mROX at baseline and six-hour values was 59.81 versus 70.68 and 67.42 versus 74.88, respectively (all p>0.05). The AUC for ROX and mROX at baseline and at six hours were statistically indifferent. Only an mROX of 4.05 (mean value) and 3.34 (Youden's J cut-off) had a sensitivity plus specificity at 156% and 163%, respectively. Conclusion Both ROX and mROX at baseline and six hours had fair-to-good accuracies and AUC; the differences were insignificant. Both ROX and mROX had better accuracies at six hours. However, only mROX < 4.05 at six hours fulfilled the sensitivity plus specificity criteria to be a clinically valuable screener.

Karim HMR ，Bharadwaj A ，Mujahid OM ，Borthakur MP ，Panda CK ，Kalbande JV ... -  《Cureus》

[Value of modified ROX index in predicting the outcome of patients with acute respiratory distress syndrome due to SARS-CoV-2 infection treated with high-flow nasal cannula oxygen therapy].

Wang X ，Zhang Z ，Cao W 《-》

Modified Respiratory Rate Oxygenation Index: An Early Warning Index for the Need of Intubation in COVID-19 Patients with High-Flow Nasal Cannula Therapy.

High-flow nasal cannula oxygen therapy (HFNC) is recommended for patients with COVID-19. However, the increasing use of HFNC brings a risk of delayed intubation. The optimal timing of switching from HFNC to invasive mechanical ventilation (IMV) remains unclear. An effective predictor is needed to assist in deciding on the timing of intubation. Respiratory rate and oxygenation (ROX) index, defined as (SpO2/FiO2) / respiratory rate, has already shown good diagnostic accuracy. Modified ROX (mROX) index, defined as (PaO2 /FiO2) / respiratory rate, might be better than the ROX index in predicting HFNC failure. The aim was to evaluate the predictive value of mROX for HFNC failure in patients with COVID-19. Severe or critical patients with COVID-19 treated with HFNC were enrolled in two clinical centers. Laboratory indicators, respiratory parameters, and mROX index at 0 h and 2 h after initial HFNC were collected. Based on the need for IMV after HFNC initiation, the patients were divided into an HFNC failure group and an HFNC success group. The predictive value of mROX index for IMV was evaluated by the area under the receiver operating characteristic curve (AUROC) and logistic regression analysis. We performed Kaplan-Meier survival analysis using the log-rank test. Sixty patients with COVID-19 (mean ± SD age, 62.8 ± 14.1 years; 42 patients were male) receiving HFNC were evaluated, including 18 critical and 42 severe cases. A total of 33 patients had hypertension; 14 had diabetes; 17 had chronic cardiac disease; 11 had chronic lung disease; 13 had chronic kidney disease; and 17 had a history of stroke. The AUROC of mROX index at 2 h was superior to that of other respiratory parameters to predict the need for IMV (0.959; p < 0.001). At the mROX index cutoff point of 4.45, predicting HFNC failure reached the optimal threshold, with specificity of 94% and sensitivity of 92%. Logistic regression analysis showed that 2-h mROX index < 4.45 was a protective factor for IMV (odd radio 0.18; 95% CI 0.05-0.64; p = 0.008). In the HFNC failure group, the median time from HFNC to IMV was 22.5 h. The 28-day mortality of the late intubation patients (≥ 22.5 h) was higher than that of the early intubation patients (< 22.5 h) (53.8% vs. 8.3%; p = 0.023). mROX at 2 h is a good early warning index of the need for IMV in patients with COVID-19 after HFNC initiation. Early intubation may lead to better survival in patients with 2-h mROX index < 4.45.

Ai T ，Zhang Z ，Tan Z ，Shi Z ，Li H ，Zhang S ，Zhao X ，Yao Y ，Li W ，Gao Y ，Zhu M ... -  《JOURNAL OF EMERGENCY MEDICINE》

Prediction of high-flow nasal cannula outcomes at the early phase using the modified respiratory rate oxygenation index.

This study was designed to explore the early predictive value of the respiratory rate oxygenation (ROX) index modified by PaO2 (mROX) in high-flow nasal cannula (HFNC) therapy in patients with acute hypoxemia respiratory failure (AHRF). Seventy-five patients with AHRF treated with HFNC were retrospectively reviewed. Respiratory parameters at baseline and 2 h after HFNC initiation were analyzed. The predictive value of the ROX (ratio of pulse oximetry/FIO2 to respiratory rate) and mROX (ratio of arterial oxygen /FIO2 to respiratory rate) indices with two variations by adding heart rate to each index (ROX-HR and mROX-HR) was evaluated. HFNC therapy failed in 24 patients, who had significantly higher intensive care unit (ICU) mortality and longer ICU stay. Both the ROX and mROX indices at 2 h after HFNC initiation can predict the risk of intubation after HFNC. Two hours after HFNC initiation, the mROX index had a higher area under the receiver operating characteristic curve (AUROC) for predicting HFNC success than the ROX index. Besides, baseline mROX index of greater than 7.1 showed a specificity of 100% for HFNC success. The mROX index may be a suitable predictor of HFNC therapy outcomes at the early phase in patients with AHRF.

Li Z ，Chen C ，Tan Z ，Yao Y ，Xing S ，Li Y ，Gao Y ，Zhao Z ，Deng Y ，Zhu M ... -  《BMC Pulmonary Medicine》

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.

Patients with mild-to-moderate coronavirus disease 2019 (COVID-19)-associated acute respiratory distress syndrome (ARDS) can be treated with a high-flow nasal cannula (HFNC). The use of the respiratory rate-oxygenation (ROX) index, calculated as the ratio of oxygen saturation (SpO2)/fractional oxygen (FiO2) to respiratory rate, in the first few hours after HFNC initiation can help identify patients who fail HFNC therapy later. However, few studies have documented the use of the ROX index during the period of HFNC therapy. Therefore, we aimed to demonstrate the diagnostic performance of the ROX index when calculated throughout the HFNC therapy period and to determine the best cut-off point for predicting HFNC failure. We conducted a retrospective study of patients with COVID-19-associated ARDS who commenced HFNC at the Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Thailand, between April 1 and August 30, 2021. We calculated the ROX index every 4 h throughout the HFNC therapy period and defined HFNC failure as a subsequent endotracheal tube intubation. The performance of the ROX index was analyzed using the area under the receiver operating characteristic curve (AUC). We applied the ROX index ≤ 4.88 to predict HFNC failure and obtained a new ROX cut-off point using Youden's method. In total, 212 patients with COVID-19 treated with HFNC were included in the study. Of these, 81 patients (38.2%) experienced HFNC failure. The ROX index ≤ 4.88 demonstrated a reasonable performance in predicting HFNC failure (AUC, 0.77; 95% confidence interval [CI], 0.72-0.83; p<0.001). However, compared with the original cut-off point of ≤ 4.88, the new ROX index cut-off point of ≤ 5.84 delivered optimal performance (AUC, 0.84; 95% CI, 0.79-0.88; p<0.001), with a significantly better discriminative ability (p = 0.007). In conclusion, a ROX index ≤ 5.84 was found to be optimal for predicting HFNC failure in patients with COVID-19-associated ARDS.

Poopipatpab S ，Nuchpramool P ，Phairatwet P ，Lertwattanachai T ，Trongtrakul K ... -  《-》