Improving Clinical Decision-making for Hypercapnic Respiratory Failure and NIV: A Multi-facility Study

INTRODUCTION: Prompt recognition of impending Non-Invasive Ventilation (NIV) failure is key for mitigating mortality in patients with respiratory insufficiency. While the HACOR (Heart rate, Acidosis, Consciousness, Oxygenation, Respiratory rate) scoring system has demonstrated potential, additional evidence is required from varied patient settings.(1,2) This investigation aimed to validate how well the HACOR score predicts NIV failure among individuals with hypercapnic respiratory failure. OBJECTIVES: To evaluate the HACOR scoring system's ability to predict Non-Invasive Ventilation (NIV) failure among patients with hypercapnic respiratory failure in a multi-facility urban healthcare setting. MATERIALS AND METHODS: This retrospective study included patients hospitalized for hypercapnic respiratory failure at various facilities in the New York City area from July 2022 to June 2023. HACOR assessments were performed 1–2 hours after NIV initiation. The primary outcome was NIV failure, defined as the requirement for intubation or death. Patient characteristics were reported as means (± SD) for continuous data and frequencies for categorical variables. Group comparisons between NIV success and NIV failure cohorts were analyzed via t-tests and chi-square tests. ROC analysis quantified the scoring system's discriminatory power, and the Youden Index determined the optimum cut point for predicting NIV failure. A p-value < 0.05 indicated statistical significance. RESULTS: Among the included population (mean age 66.7 ± 13.3 years; 51% female), 29.49% experienced NIV failure. Of the 41 patients who failed NIV, 36.58% did not survive. In contrast, 98 participants were classified as having successful NIV outcomes. Notably, patients who progressed to NIV failure exhibited an elevated average HACOR score of 9.89 ± 4.1, significantly exceeding the mean of 2.78 ± 1.6 observed in the successful group (t = -9.85, p = 4.34 × 10^(-18)). The ROC curve analysis produced an area under the curve (AUC) of 0.83, denoting solid predictive performance. Setting the cutoff score at 9 identified a high-risk subgroup, of whom 83.3% proceeded to NIV failure. This data aligns with the findings from our previous study, validating the utility of the HACOR score in predicting NIV failure in patients with COPD exacerbations. DISCUSSIONS/CONCLUSIONS: In this diverse urban healthcare network, elevated scores on the studied clinical measure strongly correlated with an increased likelihood of NIV failure in hypercapnic respiratory failure patients. The AUC of 0.80 supports the score's capacity to differentiate those at high risk, and a threshold of 9 emerged as particularly relevant for timely intervention. By recognizing patients with higher scores early, clinicians may be better positioned to implement strategies that enhance patient outcomes.(1–3)