International observational study on airway management in operating room and non-operating room anaesthesia. STARGATE Study.

According to WHO, more than 230 million major surgical procedures are carried out under general anaesthesia each year worldwide (1). Despite important technological advances, airway management remains a major challenge in anaesthesiology.

The National Audit Project 4, published in 2011, for the first time addressed the need to systematically collect information on major airway-related complications in both the anaesthesia and critical care settings. While in the critical care setting the report provided important insights for improvement, incidence of major adverse events such as death, brain damage and need for emergency surgical airway appeared underestimated in anaesthesia (2) so that for every case captured by NAP4 there may be another 720 potential airway events if we consider hypoxemia and cardiovascular collapse (3).

Traditionally, airway management in anaesthesia has been described as anatomically difficult as opposed to airway management in critical care defined as physiologically difficult.

Critically ill patients are prone to a higher airway-related risk due to their underlying hypoxemia, shock, acidosis which expose them to the high incidence of adverse events, especially cardiovascular collapse, recently reported in the INTUBE study cohort (4). Data from large prospective studies on current incidence of major peri-intubation adverse events are lacking in the anaesthesia setting, especially on outcomes such as peri-intubation cardiovascular collapse, severe hypoxemia, and cardiac arrest (5)(6).

These events are more common in case of difficulties with airway management so that first pass intubation failure significantly increases the risks (7)(8). Moreover, it has been documented that even transient hypotension during general anaesthesia, may have long-term consequences and may be associated with a worse outcome in patients undergoing non-cardiac surgery (9).