---
title: "FLOX Score Predicts HFNC Failure and Intubation Risk in Immunocompromised Children"
id: "pubmed-42670982"
canonical_url: "https://medichelpline.com/clinical-feed/pubmed-42670982"
content_type: "clinical_feed_article"
specialty: "Critical Care"
source_name: "PubMed / NCBI"
source_url: "https://pubmed.ncbi.nlm.nih.gov/42670982/"
doi: "10.1002/ppul.71814"
published_at: "2026-09-01T00:00:00.000Z"
evidence_level: "Journal Article"
license: "CC-BY-NC-4.0 / Informational Use"
---
# FLOX Score Predicts HFNC Failure and Intubation Risk in Immunocompromised Children
## Provenance & Clinical Metadata
- **Canonical URL:** https://medichelpline.com/clinical-feed/pubmed-42670982
- **Specialty:** [Critical Care](https://medichelpline.com/clinical-feed/critical-care.md)
- **Primary Source:** PubMed / NCBI
- **Source URL:** [Original Journal Publication](https://pubmed.ncbi.nlm.nih.gov/42670982/)
- **DOI:** [10.1002/ppul.71814](https://doi.org/10.1002%2Fppul.71814)
- **Published At:** 2026-09-01T00:00:00.000Z
- **Evidence Rating:** Journal Article
## Executive GIST (TL;DR)
- Study type: single-center, retrospective cohort of children and young adults (aged 0–26 years) with **immunocompromising conditions** (ICC) who received heated, humidified high-flow nasal cannula (**HFNC**) between 2021 and 2023. - Sample size: 93 subjects; HFNC failure (defined as intubation) occurred in 44 patients (47.3%). - PICU mortality among the cohort was 14% (n = 13). Median HFNC duration was 18.7 hours (IQR 6.0–40.4). - Authors developed the novel **FLOX** score defined as (flow in L/min) / weight (kg) * FiO2. - Median **FLOX** score was significantly higher in patients who failed HFNC at initiation (p = 0.04), 2 hours (p = 0.03), 4 hours (p = 0.05), and 6 hours (p = 0.05). - A FLOX threshold ≥ 0.20 was associated with increased adjusted odds of HFNC failure: initiation OR 2.5 (95% CI 1.03–5.9), 2 h OR 4.3 (95% CI 1.7–10.9), 4 h OR 6.5 (95% CI 2.5–16.8), and 6 h OR 4.9 (95% CI 1.9–12.7). - Key message: nearly half of children with ICC treated with HFNC required intubation, and a **FLOX ≥ 0.20** was associated with higher odds of HFNC failure in this cohort. - Study limitations and other methodological details beyond the abstract were not reported in the source.
## Clinical Analysis & Structured Key Points
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Affiliations Expand ### Affiliations * 1 Indiana University School of Medicine, Indianapolis, Indiana, USA. * 2 Department of Pediatrics, Division of Critical Care, Indiana University School of Medicine, Indianapolis, Indiana, USA. * 3 Riley Hospital for Children at IU Health, Indianapolis, Indiana, USA. * 4 Regenstrief Center for Biomedical Informatics, Indianapolis, Indiana, USA. * PMID: **42670982** * DOI: [ 10.1002/ppul.71814 ](https://doi.org/10.1002/ppul.71814) Item in Clipboard # Development of the Novel FLOX Score to Assess Risk of Intubation in Children With Immunocompromising Conditions Receiving High Flow Nasal Cannula Michelle A Mai et al. Pediatr Pulmonol. 2026 Sep. Show details Display options Display options Format Abstract PubMed PMID Pediatr Pulmonol Actions * [ Search in PubMed ](https://pubmed.ncbi.nlm.nih.gov/?term=%22Pediatr+Pulmonol%22%5Bjour%5D&sort=date&sort_order=desc) * [ Search in NLM Catalog ](https://www.ncbi.nlm.nih.gov/nlmcatalog?term=%22Pediatr+Pulmonol%22%5BTitle+Abbreviation%5D) * [ Add to Search ](https://pubmed.ncbi.nlm.nih.gov/42670982/) . 2026 Sep;61(9):e71814. doi: 10.1002/ppul.71814. ### Authors [Michelle A Mai](https://pubmed.ncbi.nlm.nih.gov/?term=Mai+MA&cauthor_id=42670982)[ 1 ](https://pubmed.ncbi.nlm.nih.gov/42670982/#short-view-affiliation-1 "Indiana University School of Medicine, Indianapolis, Indiana, USA."), [Colin M Rogerson](https://pubmed.ncbi.nlm.nih.gov/?term=Rogerson+CM&cauthor_id=42670982)[ 2 ](https://pubmed.ncbi.nlm.nih.gov/42670982/#short-view-affiliation-2 "Department of Pediatrics, Division of Critical Care, Indiana University School of Medicine, Indianapolis, Indiana, USA.")[ 3 ](https://pubmed.ncbi.nlm.nih.gov/42670982/#short-view-affiliation-3 "Riley Hospital for Children at IU Health, Indianapolis, Indiana, USA.")[ 4 ](https://pubmed.ncbi.nlm.nih.gov/42670982/#short-view-affiliation-4 "Regenstrief Center for Biomedical Informatics, Indianapolis, Indiana, USA."), [Courtney M Rowan](https://pubmed.ncbi.nlm.nih.gov/?term=Rowan+CM&cauthor_id=42670982)[ 2 ](https://pubmed.ncbi.nlm.nih.gov/42670982/#short-view-affiliation-2 "Department of Pediatrics, Division of Critical Care, Indiana University School of Medicine, Indianapolis, Indiana, USA.")[ 3 ](https://pubmed.ncbi.nlm.nih.gov/42670982/#short-view-affiliation-3 "Riley Hospital for Children at IU Health, Indianapolis, Indiana, USA.") ### Affiliations * 1 Indiana University School of Medicine, Indianapolis, Indiana, USA. * 2 Department of Pediatrics, Division of Critical Care, Indiana University School of Medicine, Indianapolis, Indiana, USA. * 3 Riley Hospital for Children at IU Health, Indianapolis, Indiana, USA. * 4 Regenstrief Center for Biomedical Informatics, Indianapolis, Indiana, USA. * PMID: **42670982** * DOI: [ 10.1002/ppul.71814 ](https://doi.org/10.1002/ppul.71814) Item in Clipboard Cite Display options Display options Format Abstract PubMed PMID ## Abstract **Background:** Heated, humidified, high-flow nasal cannula (HFNC) before intubation has been associated with increased mortality in children with immunocompromising conditions (ICC). **Objectives:** We sought to describe HFNC failure (intubation) rate and aimed to develop a novel score associated with HFNC failure. **Methods:** This is a single center, retrospective cohort. Patients (aged 0-26 years) with ICCs who used HFNC between 2021 and 2023 were included. **Results:** Forty-four (47.3%) of 93 included subjects failed HFNC. PICU mortality was 14% (n = 13). The median duration of HFNC was 18.7 h (IQR: 6.0, 40.4). We developed the novel FLOX ((flow in Liters/minute)/weight (kg)*FiO2) score. Median FLOX score was higher with HFNC failure at initiation (p = 0.04), 2 h (p = 0.03), 4 h (p = 0.05), and 6 h (p = 0.05). Adjusting for acuity, the odds of HFNC failure with a FLOX score (≥0.20) were as follows: Initiation OR = 2.5 (95%CI: 1.03, 5.9), p = 0.042); 2 h of HFNC, OR = 4.3 ((95%CI: 1.7, 10.9), p = 0.002); 4 h of HFNC, OR = 6.5 (95%CI: 2.5, 16.8), (p < 0.001); and 6 h of HFNC, OR = 4.9 (95%CI: 1.9, 12.7), (p = 0.001). **Conclusion:** In children with ICCs, almost half fail HFNC. Mortality was high in those who fail HFNC. The FLOX score, specifically a FLOX ≥ 0.20 is associated with increased odds of failing HFNC in our ICC cohort. **Keywords:** Immunocompromised host; Noninvasive ventilation; cancer; critical care; pediatrics; respiratory distress syndrome; respiratory insufficiency. © 2026 The Author(s). Pediatric Pulmonology published by Wiley Periodicals LLC. [PubMed Disclaimer](https://pubmed.ncbi.nlm.nih.gov/disclaimer/) ## References 1. 1. S. J. Gertz, A. Bhalla, R. S. Chima, et al., “Immunocompromised‐Associated Pediatric Acute Respiratory Distress Syndrome: Experience From the 2016/2017 Pediatric Acute Respiratory Distress Syndrome Incidence and Epidemiology Prospective Cohort Study,” Pediatric Critical Care Medicine 25, no. 4 (2024): 288–300. 2. 1. H. Kang, Z. Zhao, and Z. Tong, “Effect of High‐Flow Nasal Cannula Oxygen Therapy in Immunocompromised Subjects With Acute Respiratory Failure,” Respiratory Care 65, no. 3 (2020): 369–376. 3. 1. J. P. Frat, S. Ragot, C. Girault, et al., “Effect of Non‐Invasive Oxygenation Strategies in Immunocompromised Patients With Severe Acute Respiratory Failure: A Post‐Hoc Analysis of a Randomised Trial,” Lancet Respiratory Medicine 4, no. 8 (2016): 646–652. 4. 1. E. Azoulay, V. Lemiale, D. Mokart, et al., “Effect of High‐Flow Nasal Oxygen vs Standard Oxygen on 28‐Day Mortality in Immunocompromised Patients With Acute Respiratory Failure: The HIGH Randomized Clinical Trial,” Journal of the American Medical Association 320, no. 20 (2018): 2099–2107. 5. 1. V. Lemiale, D. Mokart, J. Mayaux, et al., “The Effects of a 2‐h Trial of High‐Flow Oxygen by Nasal Cannula Versus Venturi Mask in Immunocompromised Patients With Hypoxemic Acute Respiratory Failure: A Multicenter Randomized Trial,” Critical Care 19 (2015): 380. 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