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Failure to Plan for Failure

NextGen Learning To Elevate Your Airway Practice

Practice-Changing Evidence

NAP4 is the most extensive study of significant complications of airway management ever performed. In a national year-long survey, 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, neurological deficits, emergency surgical airway, and admission to ICU (or prolongation of stay if already in ICU).

NAP4 Summary

General Findings:

  • NAP4 analyzed over 1 million airway management episodes and identified over 180 major airway complications.
  • Airway complications were rare but often catastrophic, leading to permanent harm or death in over 60% of cases.

Key Findings by Setting:

1. Anaesthesia (Operating Theatres)

  • Poor airway assessment contributed to adverse outcomes.
  • Unrecognized esophageal intubation was a significant cause of death, often due to failure to detect or respond appropriately.
  • Failure to use capnography in intubated patients was linked to serious complications.
  • Delayed or failed emergency front-of-neck access (FONA) was a key factor in preventable deaths.

2. ICU (Intensive Care Unit)

  • Airway management in the ICU had higher complication rates than in operating theatres.
  • Tracheostomy-related complications were frequent.
  • Delayed recognition of airway obstruction was common.
  • The use of capnography was often absent, leading to undetected esophageal intubations and patient deaths.
  • Difficult airways were often not anticipated, leading to unplanned emergencies.

3. Emergency Departments (ED)

  • Many airway emergencies were managed by less experienced operators with inadequate preparation.
  • High rates of esophageal intubation and subsequent patient deaths.
  • A recurring problem was the failure to recognize and manage a “Can’t Intubate, Can’t Oxygenate” (CICO) situation.
  • Cricothyroidotomy was often attempted too late or performed poorly.

Common Themes Across Settings:

  • Capnography should be mandatory in all settings where patients are intubated.
  • Early recognition of airway difficulty and preparation for failure were critical to improving outcomes.
  • Standardized emergency airway algorithms (e.g., DAS guidelines) need better adherence.
  • Training in emergency front-of-neck access (FONA) was insufficient in many cases.
  • Better documentation and handover of known airway difficulties were needed.
  • Non-theatre environments (ICU & ED) had a disproportionately high rate of airway-related morbidity and mortality.

Key Recommendations:

  • Improved airway training for all clinicians involved in airway management.
  • Routine use of waveform capnography in all areas where airway management occurs.
  • Better recognition of at-risk patients and escalation of care when needed.
  • Implementation of airway checklists to improve preparedness.
  • Regular simulation training for emergency airway scenarios.
  • More rapid transition to front-of-neck access in failed intubation scenarios.
NAP4 Study

The Bottom Line

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