Comparison of the clinimetric properties of the two versions of the HACOR scale for predicting noninvasive ventilation failure in Brazilian patients

Matheus Pereira Nunes da Silva; Adriana Claudia Lunardi

doi:10.4266/acc.000175

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Original Article Nursing Comparison of the clinimetric properties of the two versions of the HACOR scale for predicting noninvasive ventilation failure in Brazilian patients: Acute and Critical Care 2025;40(2):322-329.
DOI: https://doi.org/10.4266/acc.000175
Published online: May 28, 2025

Matheus Pereira Nunes da Silva^1,2

, Adriana Claudia Lunardi^1,3

¹Master and Doctoral Program in Physical Therapy, Universidade Cidade de São Paulo, São Paulo, Brasil

²Physical Therapy Service, Hospital Santa Marcelina de Itaquera, São Paulo, Brasil

³Department of Physical Therapy, Universidade de São Paulo, São Paulo, Brasil

Corresponding author: Adriana Claudia Lunardi Universidade Cidade de São Paulo, 475th Cesario Galeno St, São Paulo 03071-000, Brasil Tel: +55-11-3003-1189, Email: adrianalunardi@hotmail.com

• Received: January 9, 2025 • Revised: March 14, 2025 • Accepted: April 2, 2025

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Abstract
INTRODUCTION
MATERIALS AND METHODS
RESULTS
DISCUSSION
KEY MESSAGES
NOTES
REFERENCES

Abstract

Background
Scales that detect noninvasive ventilation (NIV) failure need to have adequate clinimetric properties to be reliable. This study aimed to compare the clinimetric properties of the Heart rate, Acidosis, Consciousness, Oxygenation, Respiratory rate (HACOR) and updated HACOR scales when applied to hypoxemic adult patients undergoing NIV.
Methods
This prospective study applied the HACOR and updated HACOR scales to hypoxemic patients after one hour of NIV in an emergency department setting. A second application of the scales was performed after ten minutes to assess reliability (intraclass correlation coefficient), measurement error (standard error of measurement and minimum detectable difference), ceiling and floor effects, convergent validity by correlation (Pearson’s r) with peripheral oximetry saturation (SpO₂), and predictive validity (area under the receiver operating characteristic [ROC] curve) for the outcome of needing invasive mechanical ventilation.
Results
Sixty patients were included in this study (59.45±17.48 years; Simplified Acute Physiology Score III, 56.1±13.95; 30% with respiratory disease and 25% with cardiovascular disease). After 1 hour of NIV, patients had a HACOR score of 3 (interquartile range [IQR], 1.0–5.0) and an updated HACOR score of 5 (IQR, 3.0–8.87). Clinimetric properties were adequate for both versions of the HACOR scale but were superior for the updated version, including predictive validity (ROC [95% CI], 0.78 [0.64–0.91] vs. 0.73 [0.57–0.89]) and the absence of the ceiling effect.
Conclusions
Both versions of the HACOR scale demonstrated adequate clinimetric properties for predicting NIV failure, with the updated HACOR version showing superior predictive validity and no ceiling effect compared with the original version.
Key Words: acute respiratory failure; noninvasive ventilation; Psychometrics; reproducibility of results; validation study

INTRODUCTION

Noninvasive ventilation (NIV) is one of the respiratory therapies used for treating patients with acute respiratory failure (ARF) [1]. The goal of NIV is to improve pulmonary ventilation and oxygenation [2,3] while preventing the need for invasive mechanical ventilation (MV) and associated increases in complication rates, hospitalization time, and healthcare costs [4,5].

Despite the known benefits of NIV, inappropriate use or prolonged application can contribute to treatment failure, increasing the risk of injuries associated with heightened diaphragmatic effort and the need for MV, which in turn leads to increased intra-hospital morbidity and mortality [5,6]. The failure rate of NIV therapy is approximately 30%, with 47% of these patients’ experiencing mortality. In contrast, the mortality rate for patients in whom ventilatory therapy is successful is 10% [7].

The failure rate of NIV therapy is related to delays in clinical decision-making regarding treatment failure and the need for MV [8]. Consequently, methods to predict NIV failure and facilitate early facilitate early switching to MV when indicated. Initially, these methods were poorly standardized and depended on the healthcare team's experience or were related to parameters such as vital signs, level of consciousness, arterial blood gas, and severity scales of disease [9]. However, in 2017, a scale that aggregated parameters including Heart rate, Acidosis, Consciousness, Oxygenation, Respiratory rate (HACOR) was developed with the aim of better predicting NIV failure [9].

The HACOR scale aims to predict the risk of NIV failure in a standardized, objective manner with good accuracy. The scale score ranges from 0 to 25 points. Scores of 5 or higher indicate a risk of failure greater than 80% (with 72.6% of sensitivity and 90.2% of specificity), regardless of the patient's age, disease severity, or diagnosis [9]. However, in 2022, an updated version of this scale was introduced because the authors identified that respiratory failure was not solely due to respiratory causes but also involved broader, extrinsic factors beyond pulmonary issues. In the updated HACOR version, the patient's clinical diagnosis and the severity of the disease using the Sequential Organ Failure Assessment (SOFA) scale are also scored [10]. In this new proposal, the score is categorized into four cut-off points, with patients scoring ≤7 considered at low risk of NIV failure and those scoring >14 considered at very high risk of failure [10]. With the addition of these variables, the updated model demonstrated greater predictive capability compared to the previous version [10].

It is important to determine whether this updated version of HACOR has similar or superior clinimetric properties to the original version, since it requires more information from the patient and, therefore, is more laborious. Thus, the objective of this study was to compare the reliability, measurement error, interpretability, convergent validity, and predictive validity of the original and updated HACOR scales in patients with respiratory failure admitted to the emergency room. This is because the most common cause of admissions to the emergency department is respiratory in origin and the most commonly used treatment is NIV [11].

MATERIALS AND METHODS

This prospective observational study with repeated measures was approved by the Ethics Committee of Research Involving Human Beings at Hospital Santa Marcelina de Itaquera (CAAE 48137421.0.0000.0066), and the patients or their guardians signed the informed consent form.

Participants

Hospitalized patients in the emergency department of the hospital aged over 18 years who had hypoxemic or mixed respiratory failure with at least one of the following signs were included: decreased inspired oxygen concentration with the need for supplemental oxygen therapy, alveolar hypoventilation with decreased peripheral oxygen saturation (SpO₂) or arterial partial pressure of oxygen (PaO₂) ≤60 mm Hg, increased respiratory effort, use of accessory muscles, and paradoxical breathing at rest [12,13].

Participants were classified based on the type of ARF and its corresponding disorder following a review of electronic medical records, clinical investigation, and thorough medical assessment of the possible origin of the ARF [14,15]. Patients with contraindications for NIV were excluded [16], including: cardiac or respiratory arrest, inability to cooperate (decreased level of consciousness, drowsiness, agitation, and patient refusal), hemodynamic shock (systolic blood pressure<90 mm Hg), complex cardiac arrhythmias, encephalopathy, severe gastrointestinal bleeding, upper airway obstruction, inability to protect the airway (ineffective cough and swallowing difficulties), abundant airway secretions, abdominal distension, nausea or vomiting, acute myocardial infarction, facial trauma and deformity, recent postoperative status of facial surgery, upper airway or esophagus, claustrophobia, or immediate need for MV.

Procedure

Patient selection for this study occurred immediately upon the patient’s arrival at the emergency department. After the patient or their guardian signed the Informed Consent Form, the following data were collected: age, sex, weight, Simplified Acute Physiology Score (SAPS) 3, SpO₂, and history of previous pulmonary or cardiovascular disease. Additionally, the cause of hypoxemic or mixed ARF was classified as either pulmonary or extrapulmonary, related to either mixed disturbances or hypoventilation [14,15].

One hour after the initiation of NIV, the HACOR scale was administered by the first evaluator (test), using the Brazilian-Portuguese version translated simply. At this time, SpO₂ was also measured (comparison measure for convergent validity). After 10 minutes, the scale was re-administered by a second evaluator (inter-rater reliability test). After another 10 minutes, the HACOR scale was applied again (retest). The clinimetric properties evaluated included reliability, measurement error, ceiling and floor effects, convergent validity, and predictive validity. Analyses followed the COSMIN (Consensus-based Standards for the selection of health Measurement Instruments) criteria [17].

Instruments

The HACOR scale ranges from 0 to 25 points and reflects the sum of each score of the scale variables: heart rate 0 (if ≤120 bpm) to 1 point (if ≥121 bpm); pH 0 (if ≥7.35) to 4 points (if <7.25); Glasgow Coma Scale 0 (if =15) to 10 points (if ≤10); arterial oxygen partial pressure to fraction of inspired oxygen ratio (PaO₂/FiO₂) 0 (if >201) to 6 points (if ≤100); and respiratory rate 0 (if ≤30 bpm) to 4 points (if ≥46 bpm). Higher scores indicate higher risk of NIV failure. A score of 5 or more indicates the need for orotracheal intubation [9].

The updated HACOR scale incorporates both the original HACOR scale and the SOFA for disease severity. Additionally, it uses the patient’s diagnosis to calculate the score as follows: Original HACOR score+0.5×SOFA+2.5 if pneumonia is diagnosed, –4 if cardiogenic pulmonary edema is present, +3 if acute respiratory distress syndrome (ARDS) is present, +1.5 if immunosuppression is present, +2.5 if septic shock is present. The result is categorized into four cutoff points: patients scoring ≤7 are considered at low risk of failure, 7.5–10.5 moderate risk, 11–14 high risk, and >14 very high risk for NIV failure [10].

SpO₂ was collected through bedside monitoring and portable peripheral oximetry, as well as heart rate. Respiratory rate was also collected via bedside monitoring; however, when visualization was not available on the monitor, respiratory rate was counted manually. The Glasgow Coma Scale was also assessed at bedside [18]. pH and PaO₂ were obtained through arterial blood gas analysis conducted by the physician and sent to the hospital laboratory for analysis; evaluators then consulted the results directly from the unit’s exam system. The FiO₂ was recorded from the mechanical ventilator monitor.

Intubation Decision and Follow-up

During the patient’s clinical course, the attending physician made care decisions regarding orotracheal intubation for MV without knowledge of the HACOR score, thereby maintaining independence from the study. Patient follow-up after HACOR retest was conducted via electronic medical records, collecting the following data: need for MV, discharge date, intubation date, and date of death.

Statistical Analysis and Description of Clinimetric Properties

Patient data were subjected to descriptive analysis. The properties were analyzed as described below. Data analysis was performed using IBM SPSS statistical software version 22 (IBM Corp.), with the confidence level set at 5% (P<0.05).

Reliability refers to the degree to which the assessed instrument is free from measurement error [17]. Reliability was tested both intra-rater and inter-rater using the intraclass correlation coefficient (ICC) subtype of absolute agreement for single measures, where the variance of measurements in each participant, rather than the mean, was considered (ICC(2,1)), along with its corresponding 95% CI. The classification adopted was: less than 0.40=poor reliability; between 0.40 and 0.75=moderate reliability; between 0.75 and 0.90=substantial reliability; and greater than 0.90=excellent reliability [19].

Measurement error relates to the absolute error of measurement, which refers to how close two or more repeated measures are to each other [20]. Measurement error was tested using the standard error of measurement (SEM=test score minus retest score, divided by SD) and the minimum detectable difference with 90% confidence (minimal detectable difference 90= test score minus retest score, divided by √2×SEM) [18,21]. SEM was considered very good if <5% of the total score, good if ≥5% and <10%, questionable if ≥10% and <20%, and poor if >20% [17].

Ceiling and floor effects show the scale's ability to discriminate across different conditions (severities) of patients through scoring. They were tested by calculating the percentage of patients who achieved the maximum (ceiling) and minimum (floor) scores, and were considered present if 15% or more of individuals reached the maximum or minimum score in the assessment [21]. This indicates whether the scale has limited validity.

Convergent validity was assessed by Pearson’s correlation between the HACOR scale score and SpO₂. The correlation was classified as follows: r<0.30 indicates a weak correlation; r≥0.30 and<0.60 indicates a moderate correlation; and r≥0.60 indicates a strong correlation [21]. The a priori hypothesis considered that the correlation between the HACOR scale and SpO₂ would be negative (in direction) and moderate (in magnitude) (r≥0.60), as the direction of the scores has an inverse relationship with the patients' clinical condition, and oxygenation is one of the components of HACOR. This measure is the score of the evaluated instrument compared with other similar measures, along with hypotheses of the concepts being measured, to reduce the chance of bias [22].

Predictive validity relates to a test's ability to discriminate a future outcome [19]. The receiver operating characteristic (ROC) curve was plotted, and the area under the curve was calculated to determine the HACOR scale’s discriminative ability of the need for MV. The cut-off value for the HACOR scale was determined through ROC curve analysis and defined as the point with the maximum Youden index (i.e., sensitivity + specificity – 1) [23].

RESULTS

Ninety patients were considered eligible during the study period, and 60 completed the protocol (Figure 1). The main reasons for exclusion of patients were refusal to participate in the study (n=11), intolerance to NIV (n=7), immediate need for MV (n=5), and claustrophobia (n=3), among others. The demographic, anthropometric, and clinical characteristics of the patients are summarized in Table 1.

For scale applications, the median (interquartile range [IQR]) score was similar both in the test and retest phases (3 [1.0–5.0] vs. 3 [0.25–6.0], P=0.56)of the HACOR scale, as well as for the updated HACOR (5 [3.0–8.87] vs. 5.25 [3.0–8.87], P=0.38).

The average duration of NIV use among patients was 1.08±0.27 hours. Eighteen of the 60 patients (30%) required MV. Twenty-five patients (41.7%) included in the study had died by the end of the follow-up period.

The clinimetric properties of the original and updated versions of the HACOR scale are compared in Table 2. Intra- and inter-rater reliability were excellent for both versions of the scale, with an ICC ≥0.95 according to COSMIN [17,21,22]. Measurement error was considered very good in both versions (original HACOR version: SEM=0.25 and DMD=0.085; updated HACOR version: SEM=0 and DMD=0). Convergent validity with SpO₂ was moderate for both HACOR scales (original: r=–0.39, P=0.002; updated r=–0.42, P=0.001). Predictive validity was adequate for both versions (original: ROC=0.73; updated: ROC=0.78), being 5% upper in the updated HACOR version, and both versions had the same high level of sensitivity (0.92). The original version of HACOR showed a ceiling effect that was not observed in the updated version.

DISCUSSION

This is the first study to compare the clinimetric properties of the HACOR scale created in 2017 [9] with the updated HACOR scale from 2022 [10]. Both versions of the scale demonstrated adequate intra-rater and inter-rater reliability, measurement error, convergent validity, and predictive validity for detecting NIV failure after one hour of treatment in patients with ARF admitted to an emergency department. However, the updated version showed better performance across all properties, including the ability to predict the need for MV. The original version exhibited a ceiling effect that was not detected in the updated HACOR.

The results indicated that the HACOR scale can be applied either by the same professional or different professionals without compromising accuracy, as reliability was excellent in all scenarios and the instrument error was very low, demonstrating high applicability in clinical practice. Furthermore, comparing HACOR scale performance with single-variable assessment methods that comprise the scale, both HACOR versions were superior for detecting the need for invasive MV (92% sensitivity), whereas respiratory rate had 71% sensitivity, and the APACHE II scale achieved 86% sensitivity for predicting the same outcome [24-26]. This demonstrates that individual variables provide specific information that, when combined, becomes superior to their value alone for detecting NIV failure. However, most studies agree that diagnosis can influence the clinical decision for orotracheal intubation [24-32].

Despite both scales having adequate clinimetric properties and the slight superiority of the updated HACOR version in terms of predictive validity, the application of this version in an emergency department setting may face some barriers, as reported by Duan et al. [10]. For example, the need for multiple laboratory tests and almost immediate processing to calculate the SOFA scale, as well as to complete the patient's diagnosis [33], may compromise the usability of the updated HACOR scale. However, it improves predictive capacity since ARF is not limited to ventilatory issues alone [27-32], which may explain why this version was superior to the previous one. Conversely, the original HACOR version is practical and quick to apply [9], as it does not require a wide range of laboratory tests for risk stratification of NIV failure, making clinical decision-making more expedient. Therefore, choosing the best version of the scale to be used may depend on the routine and structure of each emergency or intensive care unit.

This study had some limitations, with the first being that the number of patients was lower than the number determined by COSMIN [17,22]. Nevertheless, the methodological rigor was high and meticulous, allowing for the acquisition of realistic and reproducible data. Additionally, many patients scored low on the scales, possibly because NIV may have achieved a high success rate in this group of patients despite the observed initial severity and high mortality rate due to extrapulmonary complications.

In conclusion, both versions of the HACOR scale have adequate clinimetric properties for detecting NIV failure, including reliability, measurement error, and convergent validity. However, the updated version demonstrates greater predictive validity and the absence of a ceiling effect compared to the original version.

KEY MESSAGES

▪ Objective assessments of the success or failure of noninvasive ventilation (NIV) are necessary to avoid delay the indication for mechanical ventilation and increasing the risk of complications.

▪ The two versions of the Heart rate, Acidosis, Consciousness, Oxygenation, Respiratory rate (HACOR) scale have adequate clinimetric properties to detect failure of NIV.

▪ The updated version of HACOR is more complex than the original version; however, it shows superior predictive validity and no ceiling effect.

NOTES

CONFLICT OF INTEREST

No potential conflict of interest relevant to this article was reported.

FUNDING

None.

ACKNOWLEDGMENTS

None.

AUTHOR CONTRIBUTIONS

Conceptualization: MPNS, ACL. Data curation: MPNS. Formal analysis: ACL. Methodology: MPNS, ACL. Project administration: MPNS, ACL. Visualization: MPNS, ACL. Writing – original draft: MPNS. Writing – review & editing: ACL. All authors read and agreed to the published version of the manuscript.

Figure 1.

Flowchart of patient enrollment. NIV: noninvasive ventilation.

Table 1.

Characteristics, cause of NIV, cause of hospitalization and type of disorder (n=60)

Variable	Value
Female	33 (55)
Age (yr)	60±18
Weight (Kg)	68.1±16.9
height (m)	1.6±0.1
SAPS 3 score	56.1±13.9
Cause of ARF
Pulmonary	30 (50.0)
Extrapulmonary	30 (50.0)
Type of distress
Mixer	53 (88)
Hypoventilation	7 (12)
Reason of hospitalization
Abdominal surgery	2 (3.0)
Cardiac or cardiovascular surgery	4 (7)
Cardiovascular disorder	18 (30)
Renal disorder	9 (15)
Hematologic disease	2 (3.0)
Liver disorder	1 (1.5)
Neurological disease	1 (1.5)
Cancer	4 (7)
Pulmonary disorder	15 (25.0)
Septicemia	4 (7)

Values are presented as number (%) or mean±standard deviation.

NIV: noninvasive ventilation; SAPS: Simplified Acute Physiology Score; ARF: acute respiratory failure.

Table 2.

Comparison of the clinimetric properties of the original and updated HACOR scales (n=60)

Variable	Value
Reliability	ICC	95% CI
HACOR inter-rater	0.95	0.92–0.97
HACOR intra avaliadores	0.97	0.96–0.98
Updated HACOR inter-rater	0.97	0.95–0.98
Updated HACOR intra avaliadores	0.98	0.98–0.99
Error of measurement	SEM	MDD
HACOR	0.25	0.085
Updated HACOR	0	0
Convergent validity	r	P-value
HACOR x SpO₂	–0.39	0.002
Updated HACOR x SpO₂	–0.42	0.001
Predictive validity	ROC	95% CI
HACOR	0.73	0.57–0.89
Updated HACOR	0.78	0.64–0.91
	Sensitivity	Specificity
HACOR	0.92	0.63
HACOR atualizada	0.92	0.55
Floor and ceiling effects	No. (%)
HACOR score
0	14 (23.3)
1.0	4 (6.7)
2.0	9 (15.0)
3.0	10 (16.7)
4.0	5 (8.3)
5.0	6 (10.0)
6.0	2 (3.3)
7.0	4 (6.7)
8.0	2 (3.3)
12.0	1 (1.7)
13.0	1 (1.7)
15.0	1 (1.7)
18.0	1 (1.7)
Updated HACOR score
0	4 (6.7)
1.0	4 (6.7)
1.5	2 (3.3)
2.0	2 (3.3)
2.5	2 (3.3)
3.0	6 (10.0)
3.5	1 (1.7)
4.0	1 (1.7)
4.5	4 (6.7)
5.0	5 (8.3)
5.5	2 (3.3)
6.0	7 (11.7)
6.5	2 (3.3)
8.0	2 (3.3)
8.5	1 (1.7)
9.0	2 (3.3)
9.5	3 (5.0)
10.0	1 (1.7)
10.5	1 (1.7)
11.0	2 (3.3)
13.5	1 (1.7)
15.5	1 (1.7)
16.5	1 (1.7)
17.0	1 (1.7)
20.5	1 (1.7)
22.5	1 (1.7)

HACOR: Heart rate, Acidosis, Consciousness, Oxygenation, Respiratory rate; ICC: intraclass correlation coefficient; SEM: standard error of measurement; MDD: minimal detectable difference; r: factor of correlation; SpO₂: peripheral oximetry saturation.

REFERENCES

1. Demoule A, Girou E, Richard JC, Taillé S, Brochard L. Increased use of noninvasive ventilation in French intensive care units. Intensive Care Med 2006;32:1747-55.Article PubMed PDF
2. Rochwerg B, Brochard L, Elliott MW, Hess D, Hill NS, Nava S, et al. Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure. Eur Respir J 2017;50:1602426.Article PubMed
3. Chiumello D, Chevallard G, Gregoretti C. Non-invasive ventilation in postoperative patients: a systematic review. Intensive Care Med 2011;37:918-29.Article PubMed PDF
4. Jaber S, Chanques G, Jung B. Postoperative noninvasive ventilation. Anesthesiology 2010;112:453-61.Article PubMed PDF
5. Glossop AJ, Shephard N, Bryden DC, Mills GH. Non-invasive ventilation for weaning, avoiding reintubation after extubation and in the postoperative period: a meta-analysis. Br J Anaesth 2012;109:305-14.Article PubMed
6. Peñuelas Ó, Esteban A. Noninvasive ventilation for acute respiratory failure: the next step is to know when to stop. Eur Respir J 2018;52:1801185.Article PubMed
7. Grieco DL, Menga LS, Eleuteri D, Antonelli M. Patient self-inflicted lung injury: implications for acute hypoxemic respiratory failure and ARDS patients on non-invasive support. Minerva Anestesiol 2019;85:1014-23.Article PubMed
8. Nava S, Navalesi P, Conti G. Time of non-invasive ventilation. Intensive Care Med 2006;32:361-70.Article PubMed PDF
9. Duan J, Han X, Bai L, Zhou L, Huang S. Assessment of heart rate, acidosis, consciousness, oxygenation, and respiratory rate to predict noninvasive ventilation failure in hypoxemic patients. Intensive Care Med 2017;43:192-9.Article PDF
10. Duan J, Chen L, Liu X, Bozbay S, Liu Y, Wang K, et al. An updated HACOR score for predicting the failure of noninvasive ventilation: a multicenter prospective observational study. Crit Care 2022;26:196.Article PDF
11. Kempker JA, Abril MK, Chen Y, Kramer MR, Waller LA, Martin GS. The epidemiology of respiratory failure in the United States 2002-2017: a serial cross-sectional study. Crit Care Explor 2020;2:e0128. Article PubMed PMC
12. Roussos C, Koutsoukou A. Respiratory failure. Eur Respir J Suppl 2003;47:3s-14s.Article PubMed
13. Suh ES, Hart N. Respiratory failure. Medicine 2012;40:293-97.Article
14. Lamba TS, Sharara RS, Singh AC, Balaan M. Pathophysiology and classification of respiratory failure. Crit Care Nurs Q 2016;39:85-93.Article
15. Gunning KE. Pathophysiology of respiratory failure and indications for respiratory support. Surg (Oxf) 2003;21:72-6.Article
16. Schettino GP, Reis MA, Galas F, Park M, Franca S, Okamoto V. Mechanical ventilation noninvasive with positive pressure. J Bras Pneumol 2007;33 Suppl 2S:S92-105.
17. Terwee CB, Mokkink LB, van Poppel MN, Chinapaw MJ, van Mechelen W, de Vet HC. Qualitative attributes and measurement properties of physical activity questionnaires: a checklist. Sports Med 2010;40:525-37.Article PubMed
18. Teasdale G, Jennett B. Assessment of coma and impaired consciousness: a practical scale. Lancet 1974;2:81-4.Article PubMed
19. Lajunen T, Özkan T. Self-report Instrument s and Methods. Porter BE. In: Handbook of traffic psychology. Elsevier; 2011, pp 43-59.
20. Anselmi P, Colledani D, Robusto E. A comparison of classical and modern measures of internal consistency. Front Psychol 2019;10:2714.Article PubMed PMC
21. Terwee CB, Bot SD, de Boer MR, van der Windt DA, Knol DL, Dekker J, et al. Quality criteria were proposed for measurement properties of health status questionnaires. J Clin Epidemiol 2007;60:34-42.Article PubMed
22. de Vet HC, Terwee CB, Mokkink LB, Knol DL. Measurement in medicine. Cambridge University Press; 2011.
23. Fluss R, Faraggi D, Reiser B. Estimation of the Youden Index and its associated cutoff point. Biom J 2005;47:458-72.Article
24. Yoshida Y, Takeda S, Akada S, Hongo T, Tanaka K, Sakamoto A. Factors predicting successful noninvasive ventilation in acute lung injury. J Anesth 2008;22:201-6.Article PDF
25. Antonelli M, Conti G, Esquinas A, Montini L, Maggiore SM, Bello G, et al. A multiple-center survey on the use in clinical practice of noninvasive ventilation as a first-line intervention for acute respiratory distress syndrome. Crit Care Med 2007;35:18-25.Article PubMed
26. Carrillo A, Gonzalez-Diaz G, Ferrer M, Martinez-Quintana ME, Lopez-Martinez A, Llamas N, et al. Non-invasive ventilation in community-acquired pneumonia and severe acute respiratory failure. Intensive Care Med 2012;38:458-66.Article PubMed PDF
27. Truwit JD, Bernard GR. Noninvasive ventilation: don’t push too hard. N Engl J Med 2004;350:2512-5.Article PubMed
28. Schnell D, Timsit JF, Darmon M, Vesin A, Goldgran-Toledano D, Dumenil AS, et al. Noninvasive mechanical ventilation in acute respiratory failure: trends in use and outcomes. Intensive Care Med 2014;40:582-91.Article PubMed PDF
29. Shu W, Guo S, Yang F, Liu B, Zhang Z, Liu X, et al. Association between ARDS etiology and risk of noninvasive ventilation failure. Ann Am Thorac Soc 2022;19:255-63.Article PubMed
30. Duan J, Chen L, Liang G, Shu W, Li L, Wang K, et al. Noninvasive ventilation failure in patients with hypoxemic respiratory failure: the role of sepsis and septic shock. Ther Adv Respir Dis 2019;13:1753466619888124.Article PubMed PMC PDF
31. Thille AW, Contou D, Fragnoli C, Córdoba-Izquierdo A, Boissier F, Brun-Buisson C. Non-invasive ventilation for acute hypoxemic respiratory failure: intubation rate and risk factors. Crit Care 2013;17:R269.Article PubMed PMC PDF
32. Committee on Diagnostic Error in Health Care; Board on Health Care Services; Institute of Medicine; The National Academies of Sciences, Engineering, and Medicine; Balogh EP, Miller BT, et al. Improving diagnosis in health care. National Academies Press; 2015.
33. Chaudhuri S, Gupta N, Adhikari SD, Todur P, Maddani SS, Rao S. Utility of the one-time HACOR score as a predictor of weaning failure from mechanical ventilation: a prospective observational study. Indian J Crit Care Med 2022;26:900-5.Article PubMed PMC

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Comparison of the clinimetric properties of the two versions of the HACOR scale for predicting noninvasive ventilation failure in Brazilian patients

Acute Crit Care. 2025;40(2):322-329. Published online May 28, 2025

DOI: https://doi.org/10.4266/acc.000175

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Figure

Comparison of the clinimetric properties of the two versions of the HACOR scale for predicting noninvasive ventilation failure in Brazilian patients

Figure 1. Flowchart of patient enrollment. NIV: noninvasive ventilation.

Figure 1.

Comparison of the clinimetric properties of the two versions of the HACOR scale for predicting noninvasive ventilation failure in Brazilian patients

Variable	Value
Female	33 (55)
Age (yr)	60±18
Weight (Kg)	68.1±16.9
height (m)	1.6±0.1
SAPS 3 score	56.1±13.9
Cause of ARF
Pulmonary	30 (50.0)
Extrapulmonary	30 (50.0)
Type of distress
Mixer	53 (88)
Hypoventilation	7 (12)
Reason of hospitalization
Abdominal surgery	2 (3.0)
Cardiac or cardiovascular surgery	4 (7)
Cardiovascular disorder	18 (30)
Renal disorder	9 (15)
Hematologic disease	2 (3.0)
Liver disorder	1 (1.5)
Neurological disease	1 (1.5)
Cancer	4 (7)
Pulmonary disorder	15 (25.0)
Septicemia	4 (7)

Variable	Value
Reliability	ICC	95% CI
HACOR inter-rater	0.95	0.92–0.97
HACOR intra avaliadores	0.97	0.96–0.98
Updated HACOR inter-rater	0.97	0.95–0.98
Updated HACOR intra avaliadores	0.98	0.98–0.99
Error of measurement	SEM	MDD
HACOR	0.25	0.085
Updated HACOR	0	0
Convergent validity	r	P-value
HACOR x SpO₂	–0.39	0.002
Updated HACOR x SpO₂	–0.42	0.001
Predictive validity	ROC	95% CI
HACOR	0.73	0.57–0.89
Updated HACOR	0.78	0.64–0.91
	Sensitivity	Specificity
HACOR	0.92	0.63
HACOR atualizada	0.92	0.55
Floor and ceiling effects	No. (%)
HACOR score
0	14 (23.3)
1.0	4 (6.7)
2.0	9 (15.0)
3.0	10 (16.7)
4.0	5 (8.3)
5.0	6 (10.0)
6.0	2 (3.3)
7.0	4 (6.7)
8.0	2 (3.3)
12.0	1 (1.7)
13.0	1 (1.7)
15.0	1 (1.7)
18.0	1 (1.7)
Updated HACOR score
0	4 (6.7)
1.0	4 (6.7)
1.5	2 (3.3)
2.0	2 (3.3)
2.5	2 (3.3)
3.0	6 (10.0)
3.5	1 (1.7)
4.0	1 (1.7)
4.5	4 (6.7)
5.0	5 (8.3)
5.5	2 (3.3)
6.0	7 (11.7)
6.5	2 (3.3)
8.0	2 (3.3)
8.5	1 (1.7)
9.0	2 (3.3)
9.5	3 (5.0)
10.0	1 (1.7)
10.5	1 (1.7)
11.0	2 (3.3)
13.5	1 (1.7)
15.5	1 (1.7)
16.5	1 (1.7)
17.0	1 (1.7)
20.5	1 (1.7)
22.5	1 (1.7)

Table 1. Characteristics, cause of NIV, cause of hospitalization and type of disorder (n=60)

Values are presented as number (%) or mean±standard deviation.

NIV: noninvasive ventilation; SAPS: Simplified Acute Physiology Score; ARF: acute respiratory failure.

Table 2. Comparison of the clinimetric properties of the original and updated HACOR scales (n=60)