https://doi.org/10.4081/monaldi.2024.3033

Respiratory rate-oxygenation index on the 3rd day is the best predictor of treatment failure in COVID-19 patients

Early Access
Submitted: April 25, 2024
Accepted: September 17, 2024
Published: October 24, 2024
ROX index, respiratory failure, COVID-19
Abstract Views: 550
PDF_EARLY VIEW: 123
SUPPLEMENTARY MATERIAL: 9
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Authors

Federico Raimondi
Respiratory Medicine Unit, ASST Papa Giovanni XXIII, Bergamo, Italy.
Stefano Centanni
Respiratory Medicine Unit, ASST Santi Paolo e Carlo, Milan; University of Milan, Italy.
Fabrizio Luppi
https://orcid.org/0000-0001-5775-5947
Department of Medicine and Surgery, University of Milan Bicocca, Milan; Respiratory Disease Unit, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy.
Stefano Aliberti
Department of Biomedical Sciences, Humanitas University, Pieve Emanuele; Respiratory Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy.
Francesco Blasi
https://orcid.org/0000-0002-2285-9970
University of Milan; Respiratory Unit and Adult Cystic Fibrosis Center, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy.
Paola Rogliani
https://orcid.org/0000-0001-7801-5040
“Tor Vergata” University, Rome; Unit of Respiratory Medicine, “Tor Vergata” Hospital Foundation, Rome, Italy.
Claudio Micheletto
https://orcid.org/0000-0002-1138-3882
Respiratory Medicine Unit, University Hospital of Verona, Italy.
Marco Contoli
Department of Translational Medicine, University of Ferrara, Italy.
Alessandro Sanduzzi Zamparelli
https://orcid.org/0000-0002-0977-2643
Department of Clinical Medicine and Surgery, Section of Respiratory Diseases, University Federico II, Azienda Ospedaliera dei Colli-Monaldi Hospital, Naples, Italy.
Marialuisa Bocchino
https://orcid.org/0000-0001-5477-072X
Department of Clinical Medicine and Surgery, Section of Respiratory Diseases, University Federico II, Azienda Ospedaliera dei Colli-Monaldi Hospital, Naples, Italy.
Paolo Busatto
https://orcid.org/0000-0002-3546-9947
Pneumology, Ospedale di Lucca, Azienda USL Toscana Nord Ovest, Lucca, Italy.
Luca Novelli
lnovelli@asst-pg23.it
https://orcid.org/0000-0002-2705-248X
Respiratory Medicine Unit, ASST Papa Giovanni XXIII, Bergamo, Italy.
Simone Pappacena
https://orcid.org/0000-0003-2495-7512
Respiratory Medicine Unit, ASST Papa Giovanni XXIII, Bergamo; University of Milan, Italy.
Luca Malandrino
Respiratory Medicine Unit, ASST Papa Giovanni XXIII, Bergamo; University of Milan, Italy.
Giorgio Lorini
https://orcid.org/0000-0002-5735-7647
Respiratory Medicine Unit, ASST Papa Giovanni XXIII, Bergamo, Italy.
Greta Cairoli
https://orcid.org/0000-0002-7012-707X
FROM Research Foundation, Papa Giovanni XXIII Hospital, Bergamo, Italy.
Fabiano Di Marco
Respiratory Medicine Unit, ASST Papa Giovanni XXIII, Bergamo; University of Milan, Italy.

Predictors of outcomes are essential to identifying severe COVID-19 cases and optimizing treatment and care settings. The respiratory rate-oxygenation (ROX) index, originally introduced for predicting the failure of non-invasive support in acute hypoxemic respiratory failure (AHRF), has not been extensively studied over time during hospitalization. This multicenter prospective observational study analyzed COVID-19-related AHRF patients admitted to eight Italian hospitals during the second pandemic wave. The study assessed the ROX index using receiver operator characteristic curves and areas under the curve with 95% confidence intervals to predict treatment failure, defined as endotracheal intubation (ETI) or death. A total of 227 patients (69.2% males) were enrolled, with a median arterial partial pressure of oxygen (PaO2)/fraction of inspired oxygen (FiO2) ratio at admission of 248 (interquartile range: 170-295). Nearly one-third (29.5%) required ETI or died during hospitalization. Those who experienced treatment failure were older (median age 70 versus 61 years, p<0.001), more likely to be current or former smokers (8.5% versus 6.4% and 42.4% versus 25.5%, p=0.039), had a higher prevalence of cardiovascular diseases (74.6% versus 46.3%, p<0.001), and had a lower PaO2/FiO2 ratio at presentation (median 229 versus 254, p=0.014). Gender, body mass index, and other comorbidities showed no significant differences. In patients who failed treatment, the ROX index was higher at presentation and worsened sharply by days 3 and 4. Conversely, in patients who survived without requiring ETI, the ROX index remained stable and reduced after 5-6 days. The ROX index's predictive ability improved notably by the third day of hospitalization, with the best cut-off value identified at 8.53 (sensitivity 75%, specificity 68%). Kaplan-Meier curves indicated that a ROX index of 8.53 or lower on days 1, 2, or 3 was associated with a higher risk of treatment failure. Thus, a single ROX index assessment on day 3 is more informative than its variability over time, with values of 8.53 or lower predicting non-invasive respiratory support failure in hospitalized COVID-19 patients.

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Ethics Approval

This study was approved by the respective ethics committees involved (Comitato etico di Bergamo - n.308-20, 05/02/2021; Comitato etico della Brianza - EC approval on 02/04/2021; Comitato etico di Ferrara - n.373/2021/Oss/AOUFe, 22/04/2021; Comitato etico Ospedale Sacco Milano - n.2021/ST/091, 19/04/2021; Comitato etico di Palermo - n.3/2021, 31/03/2021; Comitato etico Policlinico Milano - n.433/2021, 23/04/2021; Comitato etico San Paolo Milano - n.965, 21/04/2021; Comitato etico di Verona - n.3171CESC, 11/03/2021).

How to Cite

Raimondi, Federico, Stefano Centanni, Fabrizio Luppi, Stefano Aliberti, Francesco Blasi, Paola Rogliani, Claudio Micheletto, et al. 2024. “Respiratory Rate-Oxygenation Index on the 3<sup>rd< sup> Day Is the Best Predictor of Treatment Failure in COVID-19 Patients”. Monaldi Archives for Chest Disease, October. https://doi.org/10.4081/monaldi.2024.3033.
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