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LETTERS TO EDITOR
Year : 2022 | Volume
: 16
| Issue : 2 | Page : 264-265
The feasibility of ROX index to predict intubation in patients initiated on high-flow oxygenation
Abhijit Nair1, Antonio Esquinas2
1 Department of Anaesthesiology, Ibra Hospital, Ministry of Health-Oman, Ibra, Sultanate of Oman
2 Department of Intensive Care, Hospital Morales Meseguer, Murcia, Spain
Correspondence Address:
Abhijit Nair
Department of Anaesthesiology, Ibra Hospital, Ministry of Health-Oman, P.O. Box 275, Ibra-414, Sultanate of Oman
Sultanate of Oman
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/sja.sja_67_22
| Date of Submission | 24-Jan-2022 |
| Date of Decision | 25-Jan-2022 |
| Date of Acceptance | 25-Jan-2022 |
| Date of Web Publication | 17-Mar-2022 |
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How to cite this article:
Nair A, Esquinas A. The feasibility of ROX index to predict intubation in patients initiated on high-flow oxygenation. Saudi J Anaesth 2022;16:264-5 |
How to cite this URL:
Nair A, Esquinas A. The feasibility of ROX index to predict intubation in patients initiated on high-flow oxygenation. Saudi J Anaesth [serial online] 2022 [cited 2022 May 18];16:264-5. Available from: https://www.saudija.org/text.asp?2022/16/2/264/339845 |
To the Editor,
High flow nasal cannula (HFNC) has been successfully used to treat acute hypoxemic respiratory failure (AHRF) inside and outside the intensive care unit (ICU). Use of HFNC became very popular for managing COVID19 pneumonia especially outside the ICU due to limited beds.[1]
In 2016, Roca et al.[2] described the Respiratory rate–Oxygenation (ROX) index which is the ratio of oxygen saturation on pulse oximeter/fraction of inspired oxygen (SpO2/FIO2) to respiratory rate (RR). ROX index is calculated at 2 h, 6 h, and 12 h. Roca et al.[2] described ROX index in patients with AHRF with pneumonia who were initiated on HFNC. The landmark paper was a prospective study involving 157 patients who were initiated on HFNC out of which 44 patients (28%) failed HFNC and required intubation and mechanical ventilation. At 12 h, the best cutoff point for the ROX index was estimated to be 4.88 (area under the receiver operating characteristic curve (AUC) 0.74 [95% confidence interval (CI), 0.64–0.84]; P < 0.002).
During the pandemic when HFNC was used as a popular non-invasive ventilatory modality, ROX index was being increasingly utilized for ward and high-dependency admissions also in patients with COVID19 pneumonia. In a validity study by Suliman et al.,[3] the authors enrolled 69 patients with COVID19 pneumonia and AHRF, and analyzed several variables including ROX index which could be responsible for intubation. They concluded that gender and ROX index were the only significant independent predictors of intubation. In this study, the cutoff point of the ROX index on the first day of admission was ≤25.26 (90.2% of sensitivity and 75% of specificity). This value was much more than suggested by Roca et al. and also from various other studies.
In an observational study by Ferrer et al.,[4] the authors included 85 patients having AHRF due to COVID19 and were initiated on HFNC. The authors observed that HFNC failed in 47 (55.3%) patients. Out of 47, 45 patients were initially managed with non-invasive ventilation (NIV). ROX index at 24 h was the best predictor of HFNC success (AUC 0.826, 95% CI 0.593–1.00, P = 0.015) with a cutoff point of 5.35.
Later, Chandel et al.[5] performed a multicenter, retrospective, observational cohort study of 272 patients with AHRF due to COVID19 pneumonia who were initiated on HFNC in the beginning. They used ROX index to predict the success of HFNC therapy. On analysis, the authors concluded that ROX index was sensitive for the identification of patients for successfully weaning from HFNC. A ROX index of >3.0 at 2 h, 6 h, and 12 h after initiation of HFNC was 85.3% sensitive for identifying HFNC success.
To investigate the accuracy of ROX index in predicting the threshold for intubation after commencing HFNC in COVID19 AHRF outside the ICU and to evaluate the validity of the previously described thresholds, Vega et al.[6] conducted a retrospective observational analysis of prospectively collected data from three centers. On analysis, the authors concluded that a ROX value of <5.99 was associated with an increased risk of HFNC failure in COVID19 patients which was different from the threshold given by Roca et al. in non-covid patients.
Later Prakash et al.[7] performed a systematic review and meta-analysis to evaluate the validity of ROX index in predicting accuracy of HFNC failure in COVID19 patients. A total of eight studies (prospective and retrospective) involving 1301 patients were identified and analyzed. On analysis, the authors concluded that ROX index could predict HFNC failure in COVID-19 patients with AHRF. The authors suggested an optimal cutoff value close to five of ROX index within the 24 h of admission for predicting HNFC failure.
To conclude, although it appears that ROX index reliably predicts HFNC failure in AHRF due to non-covid and covid patients, further adequately powered, well-designed, multicentric studies need to be conducted to establish its reliability.
Acknowledgements
None
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | |  |
| 1. | Gaunt KA, Spilman SK, Halub ME, Jackson JA, Lamb KD, Sahr SM. High-flow nasal cannula in a mixed adult ICU. Respir Care 2015;60:1383-9.  |
| 2. | Roca O, Messika J, Caralt B, García-de-Acilu M, Sztrymf B, Ricard JD, 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;35:200-5. |
| 3. | Suliman LA, Abdelgawad TT, Farrag NS, Abdelwahab HW. Validity of ROX index in prediction of risk of intubation in patients with COVID-19 pneumonia. Adv Respir Med 2021;89:1-7. doi: 10.5603/ARM.a2020.0176. |
| 4. | Ferrer S, Sancho J, Bocigas I, Bures E, Mora H, Monclou E, et al. ROX index as predictor of high flow nasal cannula therapy success in acute respiratory failure due to SARS-CoV-2. Respir Med 2021;189:106638. doi: 10.1016/j.rmed. 2021.106638. |
| 5. | Chandel A, Patolia S, Brown AW, Collins AC, Sahjwani D, Khangoora V, et al. High-flow nasal cannula therapy in COVID-19: Using the ROX index to predict success. Respir Care 2021;66:909-19. |
| 6. | Vega ML, Dongilli R, Olaizola G, Colaianni N, Sayat MC, Pisani L, et al. COVID-19 Pneumonia and ROX index: Time to set a new threshold for patients admitted outside the ICU. Pulmonology 2022;28:13-7. |
| 7. | Prakash J, Bhattacharya PK, Yadav AK, Kumar A, Tudu LC, Prasad K. 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;66:102-8. |
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