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The 4th National Audit Project

Let's learn about the National Audit Project 4 and summarise the key learning points from this important report.

In this video Professor Tim Cook, Consultant Anaesthetist and Intensivist at Royal United Hospitals Bath, and Joint Lead of the 4th National Audit Project (NAP4), presents the key learning points from this milestone publication by the Royal College of Anaesthetists (RCoA) and the Difficult Airway Society (DAS).

Despite the recent technical and non-technical advances, airway management may sometimes still be problematic and unfortunately complications still occur. NAP4 is the largest evaluation of major airway management complications ever performed and it aimed to answer the following questions about UK practice:

  • What types of airway devices are used during anaesthesia and how often?
  • How often do major complications, leading to serious harm, occur in association with airway management in anaesthesia, in the intensive care units and in the emergency departments?
NAP4 collected data between September 2008 and August 2009 on patients who suffered death or brain damage, had an emergency surgical airway or an unplanned admission to intensive care (ICU), or a prolonged stay if they were already on ICU. During one year, 184 cases were recorded, and the full report makes for a sobering read.

The main learning points from NAP4 will be covered in more depth throughout the course. In the downloads section you can find an infographic summary of the key findings; you can also read the NAP4 Executive Summary.

The publication of NAP4 led to changes in airway management practice in the UK [2]. One example is the universal use of capnography whenever an airway device is in place or the patient is at risk of airway obstruction. This will be the focus of the next step.

Are you familiar with the key learning points from the NAP4 report before? Can you give any examples of recommendations that have been implemented in your workplace following its publication?

What are the challenges of airway management identified by NAP4, in patient groups such as the critically ill, head and neck patients, patients with tracheostomies, obstetric, paediatric, obese?

These topics will have a special focus in Week 4 and Week 5 of Airway Matters.


  1. Fourth National Audit Project. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society

  2. T. M. Cook, N. Woodall, C. Frerk. A national survey of the impact of NAP4 on airway management practice in United Kingdom hospitals: closing the safety gap in anaesthesia, intensive care and the emergency department, BJA: British Journal of Anaesthesia, Volume 117, Issue 2, August 2016, Pages 182–190

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Airway Matters

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