COVID-19 Pneumonia and ROX index: Time to set a new threshold for patients admitted outside the ICU

Pulmonology. 2022 Jan-Feb;28(1):13-17. doi: 10.1016/j.pulmoe.2021.04.003. Epub 2021 May 7.


High flow nasal cannula (HFNC) is used to treat acute hypoxemic respiratory failure (AHRF) even outside the ICU and the ROX index (pulse oximetry/fraction of inspired oxygen/respiratory rate) may predict HFNC failure.

Objective: The purpose of this investigation was therefore to verify whether the ROX index is an accurate predictor of HFNC failure for COVID-19 patients treated outside the intensive care unit (ICU) and to evaluate the validity of the previously suggested threshold.

Design: Multicenter study. Retrospective observational analysis of prospectively collected data.

Setting: 3 centres specialized in non-invasive respiratory support (Buenos Aires, Argentina; Bolzano and Treviso, Italy). Patients treated outside the ICU were analysed MEASUREMENTS: The variables to calculate the ROX index were collected during the first day of therapy at 2, 6, 12 and 24 hours and then recorded every 24 hours. HFNC failure was defined as escalation of respiratory support to invasive mechanical ventilation (IMV) or death.

Main results: A total of 35 (29%) patients failed HFNC and required intubation. ROC analysis identified the 12-hour ROX index as the best predictor of intubation with an AUC of 0.7916[CI 95% 0.6905-0.8927] and the best threshold to be 5.99[Specificity 96% Sensitivity 62%]. In the survival analysis, a ROX value <5.99 was associated with an increased risk of failure (p = 0008 log - rank test). The threshold of 4,9 identified by Roca as the best predictor in non-COVID patients, was not able to discriminate between success and failure (p = 0.4 log-rank test) in our patients.

Conclusions: ROX index may be useful in guiding the clinicians in their decision to intubate patients, especially in patients with moderate ARF, treated therefore outside the ICU. Indeed, it also demonstrates a different threshold value than reported for non-COVID patients, possibly related to the different mechanisms of hypoxia.

Keywords: AHRF; Acute hypoxemic respiratory failure; HFNC; High flow nasal cannula; Non invasive respiratory support; ROX index.

Publication types

  • Multicenter Study
  • Observational Study

MeSH terms

  • COVID-19*
  • Humans
  • Intensive Care Units
  • Intubation, Intratracheal
  • Noninvasive Ventilation* / methods
  • Oximetry
  • Oxygen Inhalation Therapy / methods*
  • Respiratory Insufficiency / therapy*
  • Respiratory Rate / physiology
  • Retrospective Studies
  • SARS-CoV-2