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Fisher & Paykel Healthcare — Technical Presentation (2019)
19 slides from Fisher & Paykel Healthcare's technical presentation, 2019
Slide 1: An Index Combining Respiratory Rate and Oxygenation to Predict Outcome of Nasal High Flow Therapy
Roca et al. 2018 American Journal of Respiratory and Critical Care Medicine An Index Combining Respiratory Rate and Oxygenation to Predict Outcome of Nasal High Flow Therapy. PM-618041 REV A © 2019 Fisher & Paykel Healthcare Limited
Slide 2: Introducing the ROX Index
Roca et al. Introducing the ROX Index 2018 An index combining respiratory rate and oxygenation to predict outcome of Nasal High Flow (NHF) therapy. SpO2/FiO2 -RR Roca et al. Am J Respir Crit Care Med. 2018 [Epub ahead of print].
Slide 3: Key points
Roca et al. Key points 2018 The ROX index can help to predict NHF therapy outcomes in patients with acute hypoxic respiratory failure (AHRF) due to pneumonia. The index can be calculated easily and repeatedly at the patient's bedside. The index is dynamic. Roca et al. Am J Respir Crit Care Med. 2018
Slide 4: Background
Roca et al. Background 2018 In a pilot study, Roca (2016) previously demonstrated that the ROX index: outperformed the diagnostic accuracy of its individual variables participants with an index ≥ 4.88 and > 12 hours of ongoing NHF therapy were less likely to be intubated, even after adjusting for po
Slide 5: Background: setting and population
Roca et al. Background 2018 Setting Five French and Spanish ICUs 2016 - 2017 Population N = 191, adults with AHRF* followed until death or discharge *AHRF defined according to the IDSA / ATS 2007 guidelines. Roca et al. Am J Respir Crit Care Med. 2018 [Epub ahead of print].
Slide 6: Methods
Roca et al. Methods 2018 A multi-center prospective non-randomized observational cohort study. INCLUSION CRITERIA EXCLUSION CRITERIA ICU patients with AHRF < 18 years old due to pneumonia, Indication for immediate intubation on NHF therapy Limitation of therapy (DNR) Elective intubation for diagnost
Slide 7: Pre-determined criteria for intubation
Roca et al. Pre-determined criteria 2018 for intubation GCS < 12 Cardiac arrest Arrhythmias Severe hemodynamic instability Two or more of the following • PaO2 < 60 mmHg or SpO2 < 90% on NHF ≥ 30 L/min FiO2 100% • Respiratory acidosis PaCO2 > 50 mmHg or Pv CO2 > 55 mmHg, pH < 7.25 • RR > 30 BPM • Ina
Slide 8: Methods: treatment regimen
Roca et al. Methods 2018 Treatment regimen Participants were on FM O2 ≥ 10 L/min with SpO2 < 92% and RR ≥ 25 breaths/min. NHF was initiated at 30 L/min, FiO2 100% FiO2 titrated with a target SpO2 > 92% Flow rate adjusted according to the maximum tolerated rate – which was achieved within the first 1
Slide 9: Methods: outcome
Roca et al. Methods 2018 Outcome Accuracy of the ROX index for predicting NHF outcomes (need for intubation or not) • Determined through Cox proportional hazards modelling • ROX index was calculated as the ratio of SpO2/ FiO2 to RR • Variables with a positive association with NHF success were in the
Slide 10: Results: baseline characteristics
Roca et al. Results 2018 Baseline characteristics CHARACTERISTIC Age (years) 63 (52 – 72) Pneumonia severity index 116 (80 – 152) APACHE II 16 (12 – 21) SOFA ICU admission 5 (3 – 7) Presence of shock (%) 20.4 At baseline these study participants were sicker than those enrolled in the pilot (Roca, 20
Slide 11: Results: ROX index threshold validated
Roca et al. Results 2018 ROX index threshold ≥ 4.88 (determinant for NHF success) was validated with three time points: 2 h (HR 0.434 [95% CI 0.264 – 0.715]; P= 0.001) 6 h (HR 0.304 [95% CI 0.182 – 0.509]; P<0.001) 12 h (HR 0.291 [95% CI 0.161 – 0.524]; P<0.001) Three time points were validated for
Slide 12: Results: respiratory variables, success vs failure
Roca et al. Results 2018 Respiratory variables during NHF therapy comparing success vs. failure (median) VARIABLE* TIME SUCCESS (N=123) FAILURE (N=68) P-VALUE# Prior to NHF 180 106 0.005 SpO2/FiO2 2h 155 109 0.003 6h 160 115 0.001 In those who had 12 h 165 113 0.001 success, a higher ROX 18 h 176 11
Slide 13: Results: ROX score margin for failure over time
Roca et al. Results 2018 ROX score margin for failure over time POSITIVE HOURS OF ROX SCORE PREDICTIVE NHF USE FOR FAILURE AUROC VALUE % 2 < 2.85 0.679 98 6 < 3.47 0.703 98 – 99 12 < 3.85 0.759 99 > 12 < 4.88 NA 80 The prediction accuracy of the ROX index increased over time. Roca et al. Am J Respir
Slide 14: Results: mortality and length of stay
Roca et al. Results 2018 Hospital and ICU mortality and length of stay (LOS) SUCCESS FAILURE N=123 N=68 P-VALUE ICU mortality 6 (4.9%) 29 (43.3%) <0.001 Hospital mortality 17 (14.3%) 33 (51.6%) <0.001 ICU LOS 6 (4 – 9) 20 (10 – 28) <0.001 Hospital LOS 17 (11 – 29) 35 (23 – 65) 0.002 Those who succee
Slide 15: Results summary
Roca et al. Results 2018 35.6 % (N=68) participants failed, requiring intubation. Median duration success: 96h (48 – 144 hours) (P=0.001). Median duration failure: 24h (12 – 60 hours) (P<0.001). The prediction accuracy of the ROX index increased overtime. Participants with NHF failure presented a lo
Slide 16: Conclusions
Roca et al. Conclusions 2018 The ROX index can help to predict the outcome of NHF therapy in patients with AHRF due to pneumonia. A ROX index of ≥ 4.88, measured at 2, 6, or 12 hours, is a determinant of NHF success. ROX index values were identified and validated for three different time points whic
Slide 17: Notes
Roca et al. Notes 2018 Adult pneumonia patients AHRF only. AIRVO™ 2 or MR850 used. Roca et al. Am J Respir Crit Care Med. 2018 [Epub ahead of print].
Slide 18: Additional resources
Roca et al. Additional resources 2018 PubMed link www.ncbi.nlm.nih.gov/pubmed/30576221 Full paper not freely available Clinical summary Clinical trial register www.clinicaltrials.gov, ID: NCT02845128 ROC explained www.youtube.com/watch?v=21Igj5Pr6u4 Roca et al. Am J Respir Crit Care Med. 2018 [Epub
Slide 19: Glossary
Roca et al. Glossary 2018 AUROC: Area under receiver operating curve. ROC: A receiver operating characteristic curve or ROC curve, is a plot illustrating the diagnosticability of a binary classifier system as its discrimination threshold is varied. HR: Hazard ratio is the ratio of (chance of an even
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