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Updated: Sep 2, 2026
Guidelines for Elective Pediatric Fiberoptic Intubation
Published on: January 17, 2011
Development of the Novel FLOX Score to Assess Risk of Intubation in Children With Immunocompromising Conditions
Michelle A Mai1, Colin M Rogerson2,3,4, Courtney M Rowan2,3
1Indiana University School of Medicine, Indianapolis, Indiana, USA.
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.
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