Airway management disasters--lessons from the United Kingdom

The Fourth National Audit Project (NAP4) was set up by the Royal College of Anaesthetists and Difficult Airway Society to provide an insight into major complications of airway management in the United Kingdom. The NAP4 found that one serious airway complication such as death, brain damage, the need for surgical airway or unexpected intensive care admission, was reported for every 5500 general anaesthetics. Most of the events happened during daytime to a senior experienced clinicians. Airway assessment was not recorded before surgery in 74% of patients that ended up with life threatening airway complications. Aspiration was responsible for 26% of life threatening airway complications and for 50% of all deaths. The NAP4 found that airway problems were twice as common in obese patients (BMI 30-35) and four times as common in morbidly obese (BMI >35). Awake fibreoptic intubation was indicated and not performed in a significant number of reported incidents. Thirty percent of serious airway complications were associated with extubation or removal of laryngeal mask airway at the end of anaesthesia. The findings of the NAP4 have the potential to significantly influence airway management practice of all anaesthetists irrespective of where in the world they practice anaesthesia.