Article Data

  • Views 328
  • Dowloads 123

Original Research

Open Access

Prediction of high-flow nasal cannula failure in patients with acute respiratory failure by measuring the cross-sectional area of the diaphragmatic crus and ROX index

  • Hyun Joon Kim1
  • Jisoo Jeong2
  • Hyung Jun Moon1
  • Hyun Jung Lee1
  • Dongkil Jeong1
  • Tae Yong Shin1
  • Jeong Ah Hwang3
  • Dongwook Lee1,*,

1Department of Emergency medicine, Soonchunhyang University Hospital, 31151 Cheonan, Republic of Korea

2Department of Hemato-oncology, Soonchunhyang University Hospital, 31151 Cheonan, Republic of Korea

3Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, 06351 Seoul, Republic of Korea

DOI: 10.22514/sv.2023.084 Vol.19,Issue 5,September 2023 pp.169-177

Submitted: 05 October 2022 Accepted: 01 December 2022

Published: 08 September 2023

*Corresponding Author(s): Dongwook Lee E-mail:


The delayed prediction of high-flow nasal cannula (HFNC) failure is associated with poor prognosis in patients with acute respiratory failure (ARF) treated with HFNCs. This study aimed to identify the early predictors for requiring mechanical ventilation (MV) in ARF patients treated with HFNCs. This was a single-center retrospective observational study based on ARF patients older than 18 years, treated with HFNC, and had chest computed tomography (CT) scans performed in the emergency department (ED) of a tertiary hospital between July 2018 and June 2020. The demographic and laboratory data were collected, and the cross-sectional area (CSA) of the diaphragmatic crus was measured on the chest CT scan. Two hundred and twenty-nine patients with ARF (92 females and 137 males) were treated with HFNCs during the study period and included in this study. Twenty-five female patients (27.17%) and 32 male patients (23.36%) required subsequent intubation and MV and were categorized as HFNC failures. Their respiratory rate-oxygenation (ROX) indexes were acquired at two hours, and the average CSA of the diaphragmatic crura was integrated to analyze the predictive power, which showed good predictive accuracy in both gender groups (area under the receiver operating characteristic curves (AUROC) for females, 0.778, and males, 0.782). The optimal ROC curve cutoff point for the average CSA of the diaphragmatic crus was estimated to be 1.48 cm2 in female patients and 1.64 cm2 in male patients. Altogether, these results indicated that the CSA measurement of the diaphragmatic crus on CT in ARF patients might help predict the risk of HFNC failure.


Respiratory failure; Emergency departments; Respiratory muscles; Computed tomography; x-ray

Cite and Share

Hyun Joon Kim,Jisoo Jeong,Hyung Jun Moon,Hyun Jung Lee,Dongkil Jeong,Tae Yong Shin,Jeong Ah Hwang,Dongwook Lee. Prediction of high-flow nasal cannula failure in patients with acute respiratory failure by measuring the cross-sectional area of the diaphragmatic crus and ROX index. Signa Vitae. 2023. 19(5);169-177.


[1] Society AT. Dyspnea: mechanisms, assessment, and management: a consensus statement. American Journal of Respiratory and Critical Care Medicine. 1999; 159: 321–340.

[2] Lenglet H, Sztrymf B, Leroy C, Brun P, Dreyfuss D, Ricard J-D. Humidified high flow nasal oxygen during respiratory failure in the emergency department: feasibility and efficacy. Respiratory Care. 2012; 57: 1873–1878.

[3] Roca O, Riera J, Torres F, Masclans JR. High-flow oxygen therapy in acute respiratory failure. Respiratory Care. 2010; 55: 408–413.

[4] Roca O, Messika J, Caralt B, García-de-Acilu M, Sztrymf B, Ricard J-D, et al. Predicting success of high-flow nasal cannula in pneumonia patients with hypoxemic respiratory failure: the utility of the ROX index. Journal of Critical Care. 2016; 35: 200–205.

[5] Chanques G, Riboulet F, Molinari N, Carr J, Jung B, Prades A, et al. Comparison of three high flow oxygen therapy delivery devices: a clinical physiological cross-over study. Minerva Anestesiologica. 2013; 79: 1344–1355.

[6] Chatila W, Nugent T, Vance G, Gaughan J, Criner GJ. The effects of high-flow vs low-flow oxygen on exercise in advanced obstructive airways disease. Chest. 2004; 126: 1108–1115.

[7] Corley A, Caruana LR, Barnett AG, Tronstad O, Fraser JF. Oxygen delivery through high-flow nasal cannulae increase end-expiratory lung volume and reduce respiratory rate in post-cardiac surgical patients. British Journal of Anaesthesia. 2011; 107: 998–1004.

[8] Parke RL, Eccleston ML, McGuinness SP. The effects of flow on airway pressure during nasal high-flow oxygen therapy. Respiratory Care. 2011; 56: 1151–1155.

[9] Williams A, Ritchie J, Gerard C. Evaluation of a high-flow nasal oxygen delivery system: gas analysis and pharyngeal pressures. Intensive Care Medicine. 2006; 32: S219.

[10] Tobin MJ, Laghi F, Jubran A. Ventilatory failure, ventilator support, and ventilator weaning. Comprehensive Physiology. 2012; 2: 2871–2921.

[11] Kang BJ, Koh Y, Lim C-M, Huh JW, Baek S, Han M, et al. Failure of high-flow nasal cannula therapy may delay intubation and increase mortality. Intensive Care Medicine. 2015; 41: 623–632.

[12] Aldrich T. Respiratory muscle fatigue. Clinics in Chest Medicine. 1988; 9: 225–236.

[13] European RS, Society AT. ATS/ERS statement on respiratory muscle testing. American Journal of Respiratory and Critical Care Medicine. 2002; 166: 518.

[14] Goligher EC, Brochard LJ, Reid WD, Fan E, Saarela O, Slutsky AS, et al. Diaphragmatic myotrauma: a mediator of prolonged ventilation and poor patient outcomes in acute respiratory failure. Lancet Respiratory Medicine. 2019; 7: 90–98.

[15] Elie A, Peter P, Marcio S, Anders P, Jordi R, Philippe RB, et al. Acute hypoxemic respiratory failure in immunocompromised patients: the Efraim multinational prospective cohort study. Intensive Care Medicine. 2017; 43: 1808–1819.

[16] Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system. Critical Care Medicine. 1985; 13: 818–829.

[17] Frat J-P, Thille AW, Mercat A, Girault C, Ragot S, Perbet S, et al. High-flow oxygen through nasal cannula in acute hypoxemic respiratory failure. New England Journal of Medicine. 2015; 372: 2185–2196.

[18] Messika J, Ahmed KB, Gaudry S, Miguel-Montanes R, Rafat C, Sztrymf B, et al. Use of high-flow nasal cannula oxygen therapy in subjects with ARDS: a 1-year observational study. Respiratory Care. 2015; 60: 162–169.

[19] Han J-Y, Lee K-N, Kang E-J, Baek JW. Quantitative computed tomography assessment of respiratory muscles in male patients diagnosed with emphysema. Journal of the Korean Society of Radiology. 2018; 78: 371–379.

[20] Antonelli M, Bonten M, Chastre J, Citerio G, Conti G, Curtis JR, et al. Year in review in Intensive Care Medicine 2011: III. ARDS and ECMO, weaning, mechanical ventilation, non-invasive ventilation, pediatrics and miscellanea. Intensive Care Medicine. 2012; 38: 542–556.

[21] Sztrymf B, Messika J, Bertrand F, Hurel D, Leon R, Dreyfuss D, et al. Beneficial effects of humidified high flow nasal oxygen in critical care patients: a prospective pilot study. Intensive Care Medicine. 2011; 37: 1780.

[22] Cuquemelle E, Pham T, Papon J-F, Louis B, Danin P-E, Brochard L. Heated and humidified high-flow oxygen therapy reduces discomfort during hypoxemic respiratory failure. Respiratory Care. 2012; 57: 1571–1577.

[23] Frat J-P, Brugiere B, Ragot S, Chatellier D, Veinstein A, Goudet V, et al. Sequential application of oxygen therapy via high-flow nasal cannula and non-invasive ventilation in acute respiratory failure: an observational pilot study. Respiratory Care. 2015; 60: 170–178.

[24] Maggiore SM, Idone FA, Vaschetto R, Festa R, Cataldo A, Antonicelli F, et al. Nasal high-flow versus Venturi mask oxygen therapy after extubation. Effects on oxygenation, comfort, and clinical outcome. American Journal of Respiratory and Critical Care Medicine. 2014; 190: 282–288.

[25] Moretti M, Cilione C, Tampieri A, Fracchia C, Marchioni A, Nava S. Incidence and causes of non-invasive mechanical ventilation failure after initial success. Thorax. 2000; 55: 819–825.

[26] Diaz AA, Martinez CH, Harmouche R, Young TP, McDonald M-L, Ross JC, et al. Pectoralis muscle area and mortality in smokers without airflow obstruction. Respiratory Research. 2018; 19: 62.

[27] McDonald M-LN, Diaz AA, Ross JC, San Jose Estepar R, Zhou L, Regan EA, et al. Quantitative computed tomography measures of pectoralis muscle area and disease severity in chronic obstructive pulmonary disease. A cross-sectional study. Annals of the American Thoracic Society. 2014; 11: 326–334.

[28] Moon SW, Choi JS, Lee SH, Jung KS, Jung JY, Kang YA, et al. Thoracic skeletal muscle quantification: low muscle mass is related with worse prognosis in idiopathic pulmonary fibrosis patients. Respiratory Research. 2019; 20: 35.

[29] Suzuki Y, Yoshimura K, Enomoto Y, Yasui H, Hozumi H, Karayama M, et al. Distinct profile and prognostic impact of body composition changes in idiopathic pulmonary fibrosis and idiopathic pleuroparenchymal fibroelastosis. Scientific Reports. 2018; 8: 1–8.

[30] Seymour JM, Ward K, Sidhu PS, Puthucheary Z, Steier J, Jolley CJ, et al. Ultrasound measurement of rectus femoris cross-sectional area and the relationship with quadriceps strength in COPD. Thorax. 2009; 64: 418–423.

Abstracted / indexed in

Science Citation Index Expanded (SciSearch) Created as SCI in 1964, Science Citation Index Expanded now indexes over 9,200 of the world’s most impactful journals across 178 scientific disciplines. More than 53 million records and 1.18 billion cited references date back from 1900 to present.

Journal Citation Reports/Science Edition Journal Citation Reports/Science Edition aims to evaluate a journal’s value from multiple perspectives including the journal impact factor, descriptive data about a journal’s open access content as well as contributing authors, and provide readers a transparent and publisher-neutral data & statistics information about the journal.

Chemical Abstracts Service Source Index The CAS Source Index (CASSI) Search Tool is an online resource that can quickly identify or confirm journal titles and abbreviations for publications indexed by CAS since 1907, including serial and non-serial scientific and technical publications.

Index Copernicus The Index Copernicus International (ICI) Journals database’s is an international indexation database of scientific journals. It covered international scientific journals which divided into general information, contents of individual issues, detailed bibliography (references) sections for every publication, as well as full texts of publications in the form of attached files (optional). For now, there are more than 58,000 scientific journals registered at ICI.

Geneva Foundation for Medical Education and Research The Geneva Foundation for Medical Education and Research (GFMER) is a non-profit organization established in 2002 and it works in close collaboration with the World Health Organization (WHO). The overall objectives of the Foundation are to promote and develop health education and research programs.

Scopus: CiteScore 1.0 (2022) Scopus is Elsevier's abstract and citation database launched in 2004. Scopus covers nearly 36,377 titles (22,794 active titles and 13,583 Inactive titles) from approximately 11,678 publishers, of which 34,346 are peer-reviewed journals in top-level subject fields: life sciences, social sciences, physical sciences and health sciences.

Embase Embase (often styled EMBASE for Excerpta Medica dataBASE), produced by Elsevier, is a biomedical and pharmacological database of published literature designed to support information managers and pharmacovigilance in complying with the regulatory requirements of a licensed drug.

Submission Turnaround Time