• T M Cook, N Woodall, J Harper, J Benger, and Fourth National Audit Project.
• Department of Anaesthesia and Intensive Care, Royal United Hospital, Combe Park, Bath, UK. timcook007@googlemail.com
• Br J Anaesth. 2011 May 1;106(5):632-42.

BackgroundThe Fourth National Audit Project of the Royal College of Anaesthetists and Difficult Airway Society (NAP4) was designed to identify and study serious airway complications occurring during anaesthesia, in intensive care unit (ICU) and the emergency department (ED).MethodsReports of major complications of airway management (death, brain damage, emergency surgical airway, unanticipated ICU admission, prolonged ICU stay) were collected from all National Health Service hospitals over a period of 1 yr. An expert panel reviewed inclusion criteria, outcome, and airway management.ResultsA total of 184 events met inclusion criteria: 36 in ICU and 15 in the ED. In ICU, 61% of events led to death or persistent neurological injury, and 31% in the ED. Airway events in ICU and the ED were more likely than those during anaesthesia to occur out-of-hours, be managed by doctors with less anaesthetic experience and lead to permanent harm. Failure to use capnography contributed to 74% of cases of death or persistent neurological injury.ConclusionsAt least one in four major airway events in a hospital are likely to occur in ICU or the ED. The outcome of these events is particularly adverse. Analysis of the cases has identified repeated gaps in care that include: poor identification of at-risk patients, poor or incomplete planning, inadequate provision of skilled staff and equipment to manage these events successfully, delayed recognition of events, and failed rescue due to lack of or failure of interpretation of capnography. The project findings suggest avoidable deaths due to airway complications occur in ICU and the ED.

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