NAP4: Major Complications of Airway Management in the United Kingdom

NAP4 Overview

NAP4 was the largest study of major complications of airway management ever performed.

A year-long national service evaluation, endorsed by all four Chief Medical Officers of the UK, NAP4 collected data between September 2008 and August 2009. NAP4 captured detailed reports of major complications of airway management in the UK. Cases were captured from all NHS hospitals in England, Scotland, Wales and Northern Ireland. Cases from Anaesthesia, Intensive Care Units and Emergency Departments were included.

NAP4 examined the most severe cases of airway complications leading to:

  • Death
  • Brain damage
  • Emergency surgical airway
  • Admission to ICU (or prolongation of stay if already on ICU).

NAP4 also surveyed anaesthetic departments to identify the number of general anaesthetics performed in the UK and how the airway was managed during these cases. NAP4 was funded by the RCoA and the joint project partners the Difficult Airway Society. Results of NAP4 were launched in March 2011.

What were the findings?

During the year 309 hospitals participated and 184 reports of airway complications were received. These included reports of 38 deaths and 18 other cases of permanent harm.

All 184 cases were reviewed in detail to identify new information and learn from these events. The report includes 168 recommendation intended to impact on national, local and personal strategy and practice in the area of airway management in order to improve patient safety.

Please see below for the NAP4 Report, which is intended for medical staff, allied health professionals, medical managers and policy makers and the public.

The full report is available either as a single PDF or split into three separate sections.

"We welcome this report and would encourage NHS trusts and staff to take note of the recommendations and take any necessary action to ensure high quality safe patient care."

Department of Health spokesperson, 2011


NAP4 Publications

NAP4 Report

Major Complications of Airway Management in the United Kingdom

NAP4 Section 1

Project description and quantitative analysis

NAP4 Report Section 2

Clinical reviews

NAP4 Paper: Part 2

Intensive care and emergency departments


Following NAP4, the President of the Royal College of Anaesthetists wrote to all Trust CEOs reinforcing several recommendations, including that all patients ventilated in theatre, the ICU or ED should be monitored with continuous capnography.

Since then, the Association of Anaesthetists of Great Britain and Ireland's Capnography Outside the Operating Theatre guidelines, the Intensive Care Society's Capnograpy Guidelines, and the European Board of Anesthesiology Capnography Recommendations have all been revised or issued.

As a consequence of these changes, not having continuous capnography on ICU or in the ED now goes against all mainstream recommendations.

NAP4 recommended that all NHS Trusts should appoint a departmental Airway Lead. Check to see if your Trust has an Airway Lead.

NAP4 Launch

Click here for launch videos and presentations, filmed at the NAP4 Report Launch held at the Royal College of Anaesthetists in 2011.

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