Identifying early predictors of high-flow nasal cannula failure in infants and children: a prospective study
Identificação de preditores precoces de falha da cânula nasal de alto fluxo em lactentes e crianças: um estudo prospectivo
Emilly Freitas de Souza, Patricia Nascimento Oliveira, Bruno Silva Miranda, Milena Siciliano Nascimento, Valéria Cabral Neves Luszczynski
Abstract
Background: High-flow nasal cannula (HFNC) is a widely used non-invasive oxygen therapy for pediatric patients with acute respiratory failure. A major clinical challenge remains with the lack of standardized criteria to assess early treatment response and to promptly identify HFNC failure. Aim: To identify and evaluate clinical predictors of HFNC failure in pediatric patients. Methods: This is a prospective observational cohort study involving 97 children aged 28 days to 14 years admitted to the Pediatric Units of a tertiary hospital who received HFNC as respiratory support were included. The indices ROX, p-ROX, S/F, RRSD and S/F/ RRSD were monitored at multiple time points. Results: The cohort consisted of 76 successes (78.4%) and 21 failures (21.6%). Within the first hour of therapy, a heart rate exceeding 167.5 beats per minute demonstrated particularly high specificity (93.4%) for subsequent failure. By the second hour, two predictors became apparent: a respiratory rate above 47.5 breaths per minute (AUC 0.67, 95% CI 0.58-0.76) and a ROX index below 5.8, which showed excellent negative predictive value (92%) that could reassure clinicians about continued HFNC suitability. The best predictor emerged at the 6-hour mark, where a ROX index below 4.8 achieved the highest discriminative capacity (AUC 0.73, 95% CI 0.65-0.81) with 91% sensitivity. While the flow-corrected S/F/RRSD ratio below 136 provided complementary specificity (82%). Conclusion: Among the evaluated parameters, the ROX index - especially at 6 hours - emerged as the most reliable predictor, achieving the highest accuracy, sensitivity, and specificity, with consistent predictive value also observed at 2 and 12 hours.
Keywords
Resumo
Introdução: A cânula nasal de alto fluxo (CNAF) é uma terapia de oxigênio não invasiva amplamente utilizada para pacientes pediátricos com insuficiência respiratória aguda. Um grande desafio clínico persiste na ausência de critérios padronizados para avaliar a resposta precoce ao tratamento e identificar prontamente a falha da CNAF. Objetivo: Identificar e avaliar preditores clínicos de falha da CNAF em pacientes pediátricos. Métodos: Este é um estudo de coorte observacional prospectivo envolvendo 97 crianças de 28 dias a 14 anos de idade, internadas nas Unidades Pediátricas de um hospital terciário, que receberam CNAF como suporte respiratório. Parâmetros clínicos e respiratórios foram monitorados em múltiplos momentos. Resultados: A coorte consistiu em 76 casos de sucesso (78,4%) e 21 falhas (21,6%). Na primeira hora de terapia, uma frequência cardíaca superior a 167,5 batimentos por minuto demonstrou especificidade alta (93,4%) para falha. Na segunda hora, 2 preditores se destacaram: a frequência respiratória acima de 47,5 respirações por minuto (AUC 0,67) e o índice ROX abaixo de 5,8, que demonstrou bom valor preditivo negativo (91,3%) e pode ajudar a tranquilizar quanto à adequação da terapia com CNAF. O melhor preditor surgiu em 6 horas, onde um índice ROX abaixo de 4,8 alcançou a maior capacidade discriminativa (AUC 0,73, IC 95% 0,65-0,81) com 91% de sensibilidade. Enquanto a relação S/F/RRSD abaixo de 136 forneceu especificidade complementar (82%). Conclusão: Entre os parâmetros avaliados, o índice ROX emergiu como o preditor mais confiável, alcançando a maior acurácia, sensibilidade e especificidade, com valor preditivo consistente também observado às 2 e 12 horas.
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References
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Submitted date:
01/24/2026
Accepted date:
05/15/2026
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