New technologies in airway management: A review.

The evolution of medical knowledge and technological growth have contributed to the development of different techniques and devices for airway management. These appear to play a role in optimizing the number of attempts and overall success, ultimately reducing the negative consequences of airway manipulation. In this literature review, we highlight the recent evidence regarding new technologies applied to airway management. Before intubation, every patient should have an individualized structured airway management plan. Technology can help with both airway evaluation and tracheal intubation. Point-of-care cervical ultrasound and artificial intelligence models with automated facial analysis have been used to predict difficult airways. Various devices can be used in airway management. This includes a robotic video endoscope that guides intubation based on real image recognition, a laryngeal mask with a non-inflatable cuff that tries to reduce local complications, video laryngeal masks that are able to confirm the correct position and facilitate intubation, Viescope™, a videolaryngoscope developed for combat medicine with a unique circular blade, a system that uses cervical transillumination for glottis identification in difficult airways and Vivasight SL™ tracheal tube, which has a high-resolution camera at its tip guaranteeing visual assurance of tube position as well as guiding bronchial blocker position. To conclude, we detailed the challenges in airway management outside the operating room as well as described suction-assisted laryngoscopy and airway decontamination technique for contaminated airways. Further research in the clinical setting is recommended to better support the use of these technologies.

Furosemide Prescription During the Dry State Is a Predictor of Long-Term Survival of Stable, Optimally Medicated Patients With Systolic Heart Failure.

BACKGROUND: Furosemide is associated with poor prognosis in patients with heart failure and reduced ejection fraction (HFrEF). AIM: To evaluate the association between daily furosemide dose prescribed during the dry state and long-term survival in stable, optimally medicated outpatients with HFrEF. POPULATION AND METHODS: Two hundred sixty-six consecutive outpatients with left ventricular ejection fraction <40%, clinically stable in the dry state and on optimal heart failure therapy, were followed up for 3 years in a heart failure unit. The end point was all-cause death. There were no changes in New York Heart Association class and therapeutics, including diuretics, and no decompensation or hospitalization during 6 months. Furosemide doses were categorized as low or none (0-40 mg/d), intermediate (41-80 mg/d), and high (>80 mg). Cox regression was adjusted for significant confounders. RESULTS: The 3-year mortality rate was 33.8%. Mean dose of furosemide was 57.3 ± 21.4 mg/d. A total of 47.6% of patients received the low dose, 42.1% the intermediate dose, and 2.3% the high dose. Receiver operating characteristics for death associated with furosemide dose showed an area under the curve of 0.74 (95% confidence interval [CI]: 0.68-0.79; P < .001), and the best cutoff was >40 mg/d. An increasing daily dose of furosemide was associated with worse prognosis. Those receiving the intermediate dose (hazard ratio [HR] = 4.1; 95% CI: 2.57-6.64; P < .001) or high dose (HR = 19.8; 95% CI: 7.9-49.6; P < .001) had a higher risk of mortality compared to those receiving a low dose. Patients receiving >40 mg/d, in a propensity score-matched cohort, had a greater risk of mortality than those receiving a low dose (HR = 4.02; 95% CI: 1.8-8.8; P = .001) and those not receiving furosemide (HR = 3.9; 95% CI: 0.07-14.2; P = .039). CONCLUSION: Furosemide administration during the dry state in stable, optimally medicated outpatients with HFrEF is unfavorably associated with long-term survival. The threshold dose was 40 mg/d.

Red blood cell distribution width is a survival predictor beyond anemia and Nt-ProBNP in stable optimally medicated heart failure with reduced ejection fraction outpatients.

BACKGROUND: RDW is an automatic value obtained with the blood count, and represents the erythrocytes dimension variation. OBJECTIVE: To evaluate in optimally medicated outpatients with heart failure with reduced ejection fraction (HFrEF) the RDW prognostic value regarding survival in a multivariable model including anemia and Nt-ProBNP. METHODS: 233 consecutive outpatients, LVEF <40%, clinically stable were followed-up for 3-years in an HF Unit. End-point was all-cause death. The RDW categorized according to the tertiles (T1 = <13.9; T2 14-15.2; T3> = 15.3). Anemia classified according to the WHO criteria. Cox survival model adjusted for clinical profile, optimal therapeutic, renal function, Nt-ProBNP, etiology, atrial fibrillation, and anemia. RESULTS: (1) The 3-years death rate was 33.5%, and increased with the RDW tertiles (17.3%; 25%; 61.1%; p < 0.001). (2) The ROC curve for death associated with RDW (AUC 0.73; p < 0.001); (3) The adjusted death risk increased with the tertiles (Hazard-ratio '[HR] = 1.61; IC 95% 1.09-2.39; p = 0.017). RDW> = 15.3 had greater adjusted death risk than T1 (HR = 2.18; 95% CI 0.99-4.8; p = 0.05) and T1+T2 (HR = 1.54; 95% CI 1.13-2.09; p = 0.006). CONCLUSION: RDW determined in optimally medicated outpatients with HFrEF, during dry-state, is a strong, cheap, and independent predictor of long-term survival.

Treatment with Optimal Dose Angiotensin-Converting Enzyme Inhibitors/Angiotensin Receptor Blockers Has a Positive Effect on Long-Term Survival in Older Individuals (Aged >70 Years) and Octogenarians with Systolic Heart Failure.

BACKGROUND: Heart failure with reduced ejection fraction (HFrEF) is a disease of older people, but the target doses of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACEIs/ARBs) are unknown. OBJECTIVE: To evaluate the association of ACEI/ARB dose level with long-term survival in stable older patients (aged >70 years) and octogenarian outpatients with HFrEF. POPULATION AND METHODS: A total of 138 outpatients aged >70 years (35.5 % > 80 years), with an LVEF <40 % and who were clinically stable on optimal therapy were followed up for 3 years. The ACEI/ARB doses were categorized as: none (0), low (1-50 % target dose), and high (50-100 % target dose). The Cox regression survival model was adjusted for age, ischemic etiology, and renal function. RESULTS: ACEIs/ARBs were prescribed to 91.3 % of patients, and 52.9 % received the high dose. Survival improved with increasing ACEI/ARB dose level in the total population (Hazard Ratio [HR] = 0.67; 95 % confidence interval [CI] 0.55-0.82; p < 0.001), older patients aged >70 years (HR = 0.65; 95 % CI 0.51-0.83; p < 0.001), and octogenarians (HR = 0.71; 95 % CI 0.51-0.99; p = 0.045). The low (HR = 0.35; 95 % CI 0.16-0.76; p = 0.008) and high doses (HR = 0.13; 95 % CI 0.06-0.32; p < 0.001) improved survival compared with not receiving ACEIs/ARBs. The high dose was associated with a better survival than the low dose in the total population (HR = 0.35; 95 % CI 0.19-0.67; p = 0.001) and in a propensity score-matched cohort (HR = 0.41; 95 % CI 0.16-1.02; p = 0.056). In octogenarians, all dose levels were associated with improved survival compared with not receiving ACEIs/ARBs, but there was no difference between ACEI/ARB doses. CONCLUSION: The achieved optimal dose of ACEIs/ARBs in ambulatory older people with HFrEF is associated with long-term survival.