![]() Flow was also gradually decreased according to the patient's tolerance and reduction of respiratory rate (RR). FiO2 was gradually reduced keeping the target SaO2. The patients were monitored by non-invasive measurement of heart rate and blood pressure, oxygen saturation and respiratory rate. The temperature was targeted according to patient comfort. HFNC was initiated with high flows of 50-60 L/min, and adjusting FiO2 to maintain SpO2 between 92-96%. Patients with a “do not intubate order” were excluded. These units provided an active full-day shift run by a fixed group of pulmonologists and with a “reinforced” nurse–patient ratio varying from 1:4 to 1:6 depending on the hospital. The respiratory COVID-19 areas consisted of a former respiratory ward, transformed into an ad-hoc dedicated specialized Respiratory Monitoring Unit. Patients treated outside the ICU were analysed. We performed a retrospective observational analysis of prospectively collected data in 120 patients with ARF due to COVID-19 pneumonia, referring to 3 centres specialized in non-invasive respiratory support (Buenos Aires, Argentina Bolzano and Treviso, Italy). The purpose of this investigation was therefore to verify, in a larger multicenter study, whether the ROX index is an accurate predictor of HFNC failure for COVID-19 patients treated outside the (ICU) and to eventually compare with the previously suggested threshold. To the best of our knowledge only one small single centre study was performed ( 10) outside the ICU and therefore generalizing about a threshold value to predict HFNC success or failure needs confirmation and verification by multicenter trials performed in less “protected environments.” ![]() This threshold was confirmed also in COVID-19 patients who show, however, an unusually high rate of intubation ( 9), compared to most of the studies performed in this population (∼30%) (1 Vianello,2 Franco,3 Patel). ( 8), identified patients at high risk of HFNC failure when this index is <4.88 at 12 hours. ROX index is defined as the ratio of pulse oximetry/fraction of inspired oxygen (SpO 2/FiO 2) to respiratory rate (RR). Failure of HFNC may cause delayed intubation and increased mortality in patients with ARF ( 7). In this latter scenario HFNC has been extensively used also outside the Intensive Care Unit (ICU) ( 2, 4), due to the paucity of ICU beds ( 5), at least in certain geographical areas ( 6). High flow nasal cannula therapy (HFNC) is increasingly used in the management of acute hypoxemic respiratory failure (AHRF), as well as during the outbreak of Coronavirus disease (COVID-19) ( 1, 2, 3).
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