The role of ROX and mROX indices in predicting intubation in COVID 19 patients treated with high flow nasal oxygen in Intensive Care Unit

İlkay Ceylan 1 * , Halil Erkan Sayan 1, Korgün Ökmen 1, Umut Öylevi 1
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1 Anesthesiology and Reanimation Department, TC University of Health Sciences, Bursa Training and Research Hospital, Bursa, Turkey
* Corresponding Author
J CLIN MED KAZ, Volume 18, Issue 3, pp. 18-22.
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Aim: In Coronavirus disease 2019 (COVID-19)-related respiratory failure, high-flow nasal oxygen (HFNO) therapy may delay invasive ventilation. The respiratory rate oxygenation (ROX) and modified ROX (mROX) indices, which can predict the need for invasive ventilation, can also be used in patients with COVID-19 with respiratory failure. The aim of the study was to verify the effectiveness of ROX and mROX to predict entubation need in HFNO therapy patients in intensive care unit.
Material and Methods: This retrospective study included 41 patients in the final evaluation.
Results: The overall mortality of patients with similar demographic and laboratory data was 60,97%. Invasive ventilation was required in 27 patients. The cutoff values for prediction of intubation for ROX and mROX at 6 h were determined as 4,95 and 6,01.
Conclusion: These indices can predict the need for invasive ventilation during the follow-up of COVİD 19 patients who under go HFNO and can help prevent adverse outcomes.


Ceylan İ, Sayan HE, Ökmen K, Öylevi U. The role of ROX and mROX indices in predicting intubation in COVID 19 patients treated with high flow nasal oxygen in Intensive Care Unit. J CLIN MED KAZ. 2021;18(3):18-22.


  • Helviz Y, Einav S. A Systematic Review of the High-flow Nasal Cannula for Adult Patients. Crit Care. 2018 20;22(1):7. DOI:10.1186/s13054-018-1990-4
  • Rola P, Farkas J, Spiegel R, Kyle-Sidell C, Weingart S, Duggan L, et al. Rethinking the early intubation paradigm of COVID-19: Time to change gears? Clin Exp Emerg Med 2020;7(2):78-80 DOI: 10.15441/ceem.20.043
  • Lyons C, Callaghan M. The use of high- fl ow nasal oxygen in COVID-19. Anaesthesia. 2020;2:843–7. DOI: 10.1111/anae.15073
  • Li J, Fink JB, Ehrmann S. High-flow nasal cannula for COVID-19 patients: Risk of bio-aerosol dispersion. European Respiratory Journal. 2020 55: 2000892. DOI: 10.1183/13993003.00892-2020
  • Kaur Matta S. Dilemmas in Covid-19 Respiratory Distress: Early vs Late Intubation; High Tidal Volume and Low PEEP vs Traditional Approach? J Intensive Crit Care. 2020;6(2):1–4. DOI:10.36648/2471-8505.6.2.7
  • Roca O, Caralt B, Messika J, Samper M, Sztrymf B, Hernández G, et al. An index combining respiratory rate and oxygenation to predict outcome of nasal high-flow therapy. Am J Respir Crit Care Med. 2019;199(11):1368–76. DOI: 10.1164/rccm.201803-0589OC
  • Goh KJ, Chai HZ, Ong TH, Sewa DW, Phua GC, Tan QL. Early prediction of high flow nasal cannula therapy outcomes using a modified ROX index incorporating heart rate. J Intensive Care. 2020;8(1):1–14. DOI: 10.1186/s40560-020-00458-z
  • Zucman N, Mullaert J, Roux D, Roca O, Ricard JD, Longrois D, et al. Prediction of outcome of nasal high flow use during COVID-19-related acute hypoxemic respiratory failure. Intensive Care Med. 2020;46(10):1924–6. DOI: 10.1007/s00134-020-06177-1
  • TC Saglik Bakanligi COVİD-19 Rehberi, 2 Nisan 2020. TC Saglik Bakanligi Halk Sagligi Genel Müdürlügü.
  • Panadero C, Abad-Fernández A, Rio-Ramírez MT, Acosta Gutiérrez CM, Calderón-Alcalá M, López-Riolobos C, et al. High-flow nasal cannula for Acute Respiratory Distress Syndrome (ARDS) due to COVID-19. Multidiscip Respir Med. 2020;15. DOI:10.4081/mrm.2020.693
  • Gattinoni L, Chiumello D, Caironi P, Busana M, Romitti F, Brazzi L, et al. COVID-19 pneumonia: different respiratory treatments for different phenotypes? Intensive Care Med. 2020;46:1099–102. DOI:10.1007/s00134-020-06033-2
  • Siempos II, Xourgia E, Ntaidou TK, Zervakis D, Magira EE, Kotanidou A, et al. Effect of Early vs. Delayed or No Intubation on Clinical Outcomes of Patients With COVID-19: An Observational Study. Front Med. 2020;7:1–6. DOI:10.3390/jcm9092847
  • Lee YH, Choi K-J, Choi SH, Lee SY, Kim KC, Kim EJ, et al. Clinical Significance of Timing of Intubation in Critically Ill Patients with COVID-19: A Multi-Center Retrospective Study. J Clin Med. 2020;9(9):2847. DOI:10.3390/jcm9092847
  • Li X, Ma X. Acute respiratory failure in COVID-19: Is it “typical” ARDS? Crit Care. 2020;24(1):1–5. DOI: 10.1186/s13054-020-02911-9
  • Chandel A, Patolia S, Brown AW, Collins AC, Sahjwani D, Khangoora V, et al. High-flow nasal cannula in COVID-19: Outcomes of application and examination of the ROX index to predict success. Respir Care. 2020;66(5):1. DOI: 10.4187/respcare.08631
  • 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. 2020;1–7. DOI: 10.5603/arm.a2020.0176
  • Calligaro GL, Lalla U, Audley G, Gina P, Miller MG, Mendelson M, et al. The utility of high-flow nasal oxygen for severe COVID-19 pneumonia in a resource-constrained setting: A multi-centre prospective observational study. EClinicalMedicine. 2020;28:100570. DOI:10.1016/j.eclinm.2020.100570
  • Blez D, Soulier A, Bonnet F, Gayat E, Garnier M. Monitoring of high-flow nasal cannula for SARS-CoV-2 severe pneumonia: less is more, better look at respiratory rate. Intensive Care Med. 2020;46:2094–5. DOI:10.1007/s00134-020-06199-9