Prediction of noninvasive ventilation failure using the ROX index in patients with de novo acute respiratory failure

Background: The ratio of SpO(2)/FiO(2) to respiratory rate (ROX) index is commonly used to predict the failure of high-flow nasal cannula. However, its predictive power for noninvasive ventilation (NIV) failure is unclear. Methods: This was a secondary analysis of a multicenter prospective observational study, intended to update risk scoring. Patients with de novo acute respiratory failure were enrolled, but hypercapnic patients were excluded. The ROX index was calculated before treatment and after 1-2, 12, and 24 h NIV. Differences in predictive power for NIV failure using the ROX index, PaO2/FiO(2), and PaO2/FiO(2)/respiratory rate were tested. Results: A total of 1286 patients with de novo acute respiratory failure were enrolled. Of these, 568 (44%) experienced NIV failure. Patients with NIV failure had a lower ROX index than those with NIV success. The rates of NIV failure were 92.3%, 70.5%, 55.3%, 41.1%, 35.1%, and 29.5% in patients with ROX index values calculated before NIV of <= 2, 2-4, 4-6, 6-8, 8-10, and > 10, respectively. Similar results were found when the ROX index was assessed after 1-2, 12, and 24 h NIV. The area under the receiver operating characteristics curve was 0.64 (95% CI 0.61-0.67) when the ROX index was used to predict NIV failure before NIV. It increased to 0.71 (95% CI 0.68-0.74), 0.74 (0.71-0.77), and 0.77 (0.74-0.80) after 1-2, 12, and 24 h NIV, respectively. The predictive power for NIV failure was similar for the ROX index and for the PaO2/FiO(2). Likewise, no difference was found between the ROX index and the PaO2/FiO(2)/respiratory rate, except at the time point of 1-2 h NIV. Conclusions: The ROX index has moderate predictive power for NIV failure in patients with de novo acute respiratory failure.