Noninvasive ventilation failure in thoracic trauma: A retrospective study on predictive scores, ventilatory strategies and pain management

Background: Blunt thoracic trauma is a major cause of respiratory failure. While most patients recover, some deteriorate, requiring invasive ventilation. The HACOR score (Heart rate, Acidosis, Consciousness, Oxygenation, Respiratory rate) and ROX index (SpO₂/FiO₂ to respiratory rate) have been used to assess the risk of non-invasive ventilatory support (NIV) failure in hypoxemic respiratory failure but have not been validated in trauma patients. Pain control and NIV strategy are key to management, yet optimal approaches remain unclear. This study assesses HACOR and ROX scores in predicting NIV failure in ICU patients with blunt thoracic trauma and explores the impact of NIV strategy and analgesia. Methods: This single-center, retrospective study included 93 patients with blunt thoracic trauma admitted to S. Chiara Hospital (Trento, Italy). The primary outcome was NIV failure, defined as the need for invasive mechanical ventilation. Results: NIV succeeded in 73 patients (78.5 %), while 20 (21.5 %) required intubation. NIV failure patients had higher HACOR scores and lower ROX index at ICU admission (5 vs. 2, p = 0.002; 8.5 vs. 14.4, p = 0.006). The lowest failure rate (13 %) was observed in patients alternating helmet CPAP and HFNC, compared to helmet CPAP alone (31 %, p = 0.05). Epidural analgesia was more common in NIV success (46.6 %; p = 0.004), while opioids predominated in NIV failure (90 %; p = 0.016). Conclusions: Higher HACOR and lower ROX scores at ICU admission were associated with NIV failure in blunt thoracic trauma patients. Alternating HFNC and CPAP showed lower NIV failure rates, as was epidural analgesia.