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NAP4 July Poster
NAP4 July Poster

What is NAP4?

NAP4 is 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, 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 was only able to examine the most severe complications and as a result inclusion criteria were 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. NAP4 was launched with a series of lectures in March 2011.

What were the findings?

There are several papers and a report produced presenting and discussing the findings. All are freely available without restriction. During the year 309 hospitals participated and 184 reports 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.

Who is the report for?

The report and resources are freely available from anyone who wishes to read it. It is likely to interest medical staff, allied health professionals, medical managers and policy makers and the public. The team worked hard to ensure the findings and recommendations of NAP4 are readily available to all who wish to read them (or have them read to them!). This brief article updates on progress of dissemination.

Sources of information

The original papers
The scientific papers are published by the project team are made freely available by the British Journal of Anaesthesia at
Census paper: click here
Paper 1 Anaesthesia: click here
Part 2 ICU and the ED: click here
There have been a total of 9 letters to the editor in response to NAP4 published in the BJA and one in Anaesthesia.

The report
The full report is available to download at click here. The full report was downloaded more than 26,000 times in the first four months after launch.

NAP4 launch presentations
All the original presentations from the NAP4 launch are available as power point slide sets at click here. The website has been accessed more than 800 times.

NAP4 podcast update
Podcasts of all the NAP4 launch talks are available for streaming from the College website at click here

NAP4 on iTunes
The podcasts can be downloaded onto mobile devices for listening to at leisure via Podbean / i-tunes at click here

In the first 6 months of this service there were >4000 downloads from 26 different countries as far distant as USA, Australia, Cambodia and Japan.

Is anyone listening?

On the day of the launch a Department of Health spokesperson said "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". 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 click here, the Intensive Care Society click here and the European Board of Anesthesiology click here have all revised guidelines or issued statements on capnography. As a consequence of these changes to not have continuous capnography on your ICU (or in the ED) now goes against all mainstream recommendations.

The RCoA and DAS has recently announced that all Departments of Anaesthesia are 'strongly recommended' to have a named RCoA DAS Departmental Airway Lead.

What others said about NAP4?

"The findings make compelling reading and should constitute a clarion call to our discipline......... an almost Herculean task of data collection and analysis"
Anaesthesia Editorial, 2011

"well organised..... NAP4 undertook a challenging task.....the report impressively succeeds in its goal"
Anesthesiology, 2011

"the content is pure gold......what does the 216 page book have that the 29 pages of the summary articles don't? The answer is 'Plenty!'......the clinical detail along with the excellent layout is what makes this book so engaging......a powerful learning tool.......overall I found this book to be excellent"
M Waddington, Anaesthesia and Intensive Care, 2011

"impressive study not previously seen.......very well written......fascinating reading....immense detailing...... the amount of effort and passion the researchers into this research project spanning four countries for a period of four years is staggering, and the dividends pay off handsomely for all of my opinion this study will become the standard for airway research in large populations"
Laura Duggan, Canadian Journal of Anaesthesia, 2011

"This report represents the most definitive source of information on serious airway complications in the UK and provides the most useful data to the world."
Takashi Asai. In Rapid-sequence induction of anesthesia in obstetric women: how safe is it? J Anesth (2012) 26: 321-323

"lessons can and must be learned from this practice-changing piece of work..... our view is that NAP4 will prove to be a seminal work in the field of airway management and it is our responsibility as clinicians to take this opportunity to use these data to facilitate change and improve the safety of airway management in anaesthesia, critical care and emergency medicine
McGuire B, Curtis R. Audits: What have we done? RCoA Bulletin In press Oct 2012

"the groundbreaking project....... a seminal project with enormous implications....highly recommended reading'
ANZCA Bulletin, 2011

"This is essential reading for all anaesthetists. The book delivers vitally important sobering results on a subject fundamental to anaesthesia. It is easy and compelling reading, with useful recommendations. It is very successful in delivering its message that airway complications can be catastrophic happen frequently, and need to be learnt from. It makes recommendations which we have used and implemented in our hospital. I cannot think of a more influential anaesthetic text in the last few years. Its subject matter and message are of unique and vital importance in anaesthesia. We have used its recommendations to make our large anaesthetic department in a teaching hospital safer. I believe every anaesthetist should read it."
BMA Medical Book of the Year Awards, 2011

Shortlisted for BMA Medical Book of the Year, 2011.
click here