Rox Index Dynamics According to High Flow Nasal Cannula Success in Intensive Care Unit Patients with COVID-19-Related Acute Respiratory Failure

Balkan Med J. 2023 Mar 8;40(2):111-116. doi: 10.4274/balkanmedj.galenos.2022.2022-6-31. Epub 2023 Jan 30.


Background: High-flow nasal cannula therapy has been shown to be useful in the treatment of patients with acute respiratory failure caused by severe acute respiratory syndrome-coronavirus disease-2. The ROX index can help predict the success of high-flow nasal cannula in coronavirus disease-19-related acute respiratory failure. However, the timing of ROX- index assessment is still unclear to protect the patients from complications due to early or delayed intubation.

Aims: To evaluate the relation between ROX index patterns within the first 48 hours of the therapy and high-flow nasal cannula success rates. The secondary aim was to determine other possible predictors of high-flow nasal cannula failure.

Study design: A cross-sectional study.

Methods: Patients admitted to the intensive care unit between April 2020 and January 2022 with coronavirus disease-19-related acute respiratory failure and treated with high-flow nasal cannula were included in the study. Patients’ demographics, clinical characteristics and laboratory findings at intensive care unit admission; ROX indices at initiation, 2nd, 8th, 12th, 24th and 48th hours of high-flow nasal cannula; and outcomes were recorded.

Results: In the study period, 69th patients were managed with high-flow nasal cannula for at least 2 hours. While 24 patients (34.7%) were successfully weaned from high-flow nasal cannula, 45 (65.3%) patients failed. Overall mortality at day 28 was 44.9%. ROX indices were lower in the high-flow nasal cannula failure group through the 12th, 24th, and 48th hours of the therapy, no significant change was observed (P = 0.33). While an overall increase in ROX index patterns were detected in patients weaned from high-flow nasal cannula (P = 0.002). Pairwise analyses revealed that ROX indexes remain stable during the first 8th hours in both groups, then improved to 12th hours of the therapy in successfully high-flow nasal cannula-weaned patients.

Conclusion: Dynamic assessments of the ROX indexes could be more suggestive rather than a point assessment to identify patients who would benefit from the high-flow nasal cannula or deteriorate in coronavirus disease-19 related acute respiratory failure.

MeSH terms

  • COVID-19* / complications
  • COVID-19* / therapy
  • Cannula / adverse effects
  • Cross-Sectional Studies
  • Humans
  • Intensive Care Units
  • Oxygen Inhalation Therapy
  • Respiratory Distress Syndrome* / therapy
  • Respiratory Insufficiency* / etiology
  • Respiratory Insufficiency* / therapy
  • SARS-CoV-2