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      Association between respiratory rate oxygenation index and need for positive pressure ventilation in children on high flow nasal cannula for bronchiolitis

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          Abstract

          Our objective was to evaluate the association of respiratory rate oxygenation index (ROX) with the need for positive pressure ventilation in children < 2 years of age with bronchiolitis on high flow nasal cannula (HFNC) therapy. We performed a single-center prospective observational study of a convenience sample of children < 2 years of age with bronchiolitis who had HFNC initiated in the pediatric emergency department between November and March, 2018–2020. ROX was calculated as pulse oximetry/FiO 2/respiratory rate at HFNC initiation. Demographics, need for positive pressure ventilation (PPV), disposition, and hospital length of stay were collected. Logistic regression model was used to determine the odds ratio for PPV need relative to the highest ROX quartile. Of the 373 patients included, 49 (13.1%) required PPV. ROX was lower in patients who required PPV compared with those who did not (5.86 [4.71–7.42] vs. 6.74 [5.46–8.25]; p = 0.01). Logistic regression revealed that those patients whose ROX was in the lowest quartile (< 5.39) were three times more likely to require PPV compared to those in the highest quartile (> 8.21). These results held true after adjusting for confounders (odds ratio 3.1; 95% CI [1.3 to 7.5]; p = 0.02). The model’s AUROC (0.701) indicated acceptable discrimination between cases and controls.

          Conclusion: Low ROX index was associated with the need for PPV in children with bronchiolitis on HFNC. The risk stratification provided and ROX threshold for risk stratification require confirmation in other populations with a larger sample size.

          What is Known:

          • Demographic and clinical factors associated with high flow nasal cannula (HFNC) therapy in children with bronchiolitis has been studied.

          What is New:

          • This is the first study to  report the utility of association of Respiratory Rate Oxygenation (ROX) index for need for positive pressure ventilation (PPV) in children  < 2 years of age with bronchiolitis on HFNC therapy.

          • ROX was lower in children who required PPV and children whose ROX was in the lowest quartile (< 5.39) were three times more likely to require PPV compared to those in the highest quartile (> 8.21).

          Supplementary Information

          The online version contains supplementary material available at 10.1007/s00431-022-04607-4.

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          An Index Combining Respiratory Rate and Oxygenation to Predict Outcome of Nasal High-Flow Therapy

          Oriol Roca, Berta Caralt, Jonathan Messika … (2019)
          Rationale: One important concern during high-flow nasal cannula (HFNC) therapy in patients with acute hypoxemic respiratory failure is to not delay intubation. Objectives: To validate the diagnostic accuracy of an index (termed ROX and defined as the ratio of oxygen saturation as measured by pulse oximetry/FiO2 to respiratory rate) for determining HFNC outcome (need or not for intubation). Methods: This was a 2-year multicenter prospective observational cohort study including patients with pneumonia treated with HFNC. Identification was through Cox proportional hazards modeling of ROX association with HFNC outcome. The most specific cutoff of the ROX index to predict HFNC failure and success was assessed. Measurements and Main Results: Among the 191 patients treated with HFNC in the validation cohort, 68 (35.6%) required intubation. The prediction accuracy of the ROX index increased over time (area under the receiver operating characteristic curve: 2 h, 0.679; 6 h, 0.703; 12 h, 0.759). ROX greater than or equal to 4.88 measured at 2 (hazard ratio, 0.434; 95% confidence interval, 0.264-0.715; P = 0.001), 6 (hazard ratio, 0.304; 95% confidence interval, 0.182-0.509; P < 0.001), or 12 hours (hazard ratio, 0.291; 95% confidence interval, 0.161-0.524; P < 0.001) after HFNC initiation was consistently associated with a lower risk for intubation. A ROX less than 2.85, less than 3.47, and less than 3.85 at 2, 6, and 12 hours of HFNC initiation, respectively, were predictors of HFNC failure. Patients who failed presented a lower increase in the values of the ROX index over the 12 hours. Among components of the index, oxygen saturation as measured by pulse oximetry/FiO2 had a greater weight than respiratory rate. Conclusions: In patients with pneumonia with acute respiratory failure treated with HFNC, ROX is an index that can help identify those patients with low and those with high risk for intubation. Clinical trial registered with www.clinicaltrials.gov (NCT02845128).
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            Predicting success of high-flow nasal cannula in pneumonia patients with hypoxemic respiratory failure: The utility of the ROX index.

            Oriol Roca, Jonathan Messika, Berta Caralt … (2016)
            The purpose of the study is to describe early predictors and to develop a prediction tool that accurately identifies the need for mechanical ventilation (MV) in pneumonia patients with hypoxemic acute respiratory failure (ARF) treated with high-flow nasal cannula (HFNC).
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              Trends in Bronchiolitis Hospitalizations in the United States: 2000–2016

              Michimasa Fujiogi, Tadahiro Goto, Hideo Yasunaga … (2019)
              From 2000 to 2016, the incidence of bronchiolitis hospitalization and mortality in US children decreased, whereas mechanical ventilation use and hospital cost substantially increased. OBJECTIVES: To investigate the temporal trend in the national incidence of bronchiolitis hospitalizations, their characteristics, inpatient resource use, and hospital cost from 2000 through 2016. METHODS: We performed a serial, cross-sectional analysis of nationally representative samples (the 2000, 2003, 2006, 2009, 2012, and 2016 Kids’ Inpatient Databases) of children (age <2 years) hospitalized for bronchiolitis. We identified all children hospitalized with bronchiolitis by using International Classification of Diseases, Ninth Revision, Clinical Modification 466.1 and International Classification of Diseases, 10th Revision, Clinical Modification J21. Complex chronic conditions were defined by the pediatric complex chronic conditions classification by using inpatient data. The primary outcomes were the incidence of bronchiolitis hospitalizations, mechanical ventilation use, and hospital direct cost. We examined the trends accounting for sampling weights. RESULTS: From 2000 to 2016, the incidence of bronchiolitis hospitalization decreased from 17.9 to 13.5 per 1000 person-years in US children (25% decrease; P trend < .001). In contrast, the proportion of bronchiolitis hospitalizations among overall hospitalizations increased from 16% to 18% ( P trend < .001). There was an increase in the proportion of children with a complex chronic condition (6%–13%; 117% increase), hospitalization to children’s hospital (15%–29%; 93% increase), and mechanical ventilation use (2%–5%; 184% increase; all P trend < .001). Likewise, the hospital cost increased from $449 million to $734 million (63% increase) nationally (with an increase in geometric mean of cost per hospitalization [from $3267 to $4086; 25% increase; P trend < .001] adjusted for inflation) from 2003 to 2016. CONCLUSIONS: From 2000 through 2016, the incidence of bronchiolitis hospitalizations among US children declined. In contrast, mechanical ventilation use and nationwide hospital direct cost substantially increased.
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                Author and article information

                Contributors
                Nirupama Kannikeswaran:
                ORCID: http://orcid.org/0000-0002-6946-9857
                nkannike@dmc.org
                Peter Whittaker: peter.whittaker@gtc.ox.ac.uk
                Usha Sethuraman: usethu@dmc.org
                Journal
                Journal ID (nlm-ta): Eur J Pediatr
                Journal ID (iso-abbrev): Eur J Pediatr
                Title: European Journal of Pediatrics
                Publisher: Springer Berlin Heidelberg (Berlin/Heidelberg )
                ISSN (Print): 0340-6199
                ISSN (Electronic): 1432-1076
                Publication date (Electronic): 14 September 2022
                Pages: 1-7
                Affiliations
                [1 ]GRID grid.414154.1, ISNI 0000 0000 9144 1055, Carman and Ann Adams Department of Pediatrics, , Children’s Hospital of Michigan, Central Michigan University, ; 3901 Beaubien Blvd, Detroit, MI 48201 USA
                [2 ]GRID grid.4991.5, ISNI 0000 0004 1936 8948, Green Templeton College, , University of Oxford, ; Oxford, OX26HG UK
                Author notes

                Communicated by Peter de Winter.

                Author information
                http://orcid.org/0000-0002-6946-9857
                Article
                Publisher ID: 4607
                DOI: 10.1007/s00431-022-04607-4
                PMC ID: 9525568
                PubMed ID: 36102995
                SO-VID: 10c76dbd-2fb9-4a5b-9355-f84555a7f759
                Copyright © © The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature 2022, Springer Nature or its licensor holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.
                License:

                This article is made available via the PMC Open Access Subset for unrestricted research re-use and secondary analysis in any form or by any means with acknowledgement of the original source. These permissions are granted for the duration of the World Health Organization (WHO) declaration of COVID-19 as a global pandemic.

                History
                Date received : 3 June 2022
                Date revision received : 27 August 2022
                Date accepted : 1 September 2022
                Categories
                Subject: Research

                ScienceOpen disciplines: Pediatrics
                Keywords: high flow nasal cannula oxygen,positive pressure ventilation,bronchiolitis,children
                Data availability:
                ScienceOpen disciplines: Pediatrics
                Keywords: high flow nasal cannula oxygen, positive pressure ventilation, bronchiolitis, children

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