NAP4 – two years on

NAP4, the 4th National Audit Project of the Royal College of Anaesthetists (RCoA) and the Difficult Airway Society (DAS) on ‘Major Complications of Airway Management in the United Kingdom’, was published in March 2011.

Two years on, the key findings of the report continue to resonate. These include:

  • A high failure rate of emergency cannula cricothyroidotomy
  • Failure to correctly interpret a capnograph trace leading to several oesophageal intubations going unrecognised in anaesthesia.
  • Numerous cases where awake fibreoptic intubation (AFOI) was indicated but was not used.
  • Problems arising when difficult intubation was managed by multiple repeat attempts at intubation.

Poor airway assessment, a failure to plan for failure and poor judgement were also identified as key clinical themes in a number of the cases reported. Such is the breadth of NAP4, that the above represent little more than a highly selective short-list.

Interestingly, when the report was launched, one of the authors highlighted in a presentation on ‘Aspiration of gastric contents and of blood‘, which can be seen as a podcast on the RCoA web-site, that ‘there’s nothing new in NAP4’, referring to the fact that one of the major findings of the report (perhaps the major finding?), that aspiration of gastric contents was the single commonest cause of death in anaesthesia events, was also the finding of a report published in Anaesthesia way back in 1956 entitled, ‘Deaths associated with anaesthesia: A report on 1,000 cases‘. So, despite all the advances in airway management and anaesthesia over the last 50 years, aspiration remains a major concern.

For many, I am sure NAP4 did highlight a lot that was new, or at the very least, NAP4 probably provided evidence to support what logic and personal experience had suggested might be true. The ultimate judgement on the success of the report may only become evident in the years ahead, when it can be assessed what practical changes have been made in light of the many recommendations of the report.

A number of posters and abstracts at national and international conferences have already assessed or reported on changes implemented in their departments in the light of NAP4. At the annual DAS meeting in 2011, these included the following:

Audit comparing supraglottic airway (SAD) device use at a DGH to NAP4 guidelines. Thomas S – This poster reported on SAD use in obese patients, use in procedures with risk of reflux or previous difficult intubation and supraglottic training and awareness of NAP4.

Post NAP4 – Implications for intensive care nursing. Lamb RG et al – A report on a project looking at basic awareness of ICU nursing staff regarding Rapid Sequence Induction (RSI) and their familiarity with difficult airway equipment. The results were used to assess the need for further education of nursing staff who may be expected to assist with RSI.

Capnography use in ICU. Measuring up to NAP4. Cole S et al – A poster reporting on the results of a survey to measure capnography use in ICUs across Scotland and to describe factors influencing use.

Capnography use outside of theatres in the Northern Deanery before and after publication of NAP4. Metcalfe SE et al – An audit on use of capnography in the UK for patients undergoing anaesthesia and being intubated irrespective of location.

Some of the recommendations of NAP4, such as each department of anaesthesia having a ‘Departmental Airway Lead’, have long been advocated by the UK Difficult Airway Society. Many hospitals already have an airway lead, but following discussions between DAS and the RCoA, the college council has endorsed a strong recommendation that all anaesthesia departments should conform with this NAP4 recommendation. The responsibilities of the position should include, the overseeing of local airway training, ensuring local policies exist and are disseminated for predictable airway emergencies, liasing specifically with ICU and emergency departments to ensure consistency, and ensuring that difficult airway equipment is appropriate to the local guidelines and standardised within the organisation.

Further potential responsibilities have also been outlined. The RCoA intends to maintain a database of departmental airway leads. DAS also plans two follow-up surveys to study the impact of NAP4. A National survey of institutional responses to NAP4 and a national ‘sprint audit’ to collect national data on practice and activity over a short period. We await the results with interest. See the DAS Newsletter – Projects Edition December 2012 pp6-7 for further details

NAP5 – Accidental Awareness during General Anaesthesia in the United Kingdom, has just been published, but two years on from publication, its predecessor remains essential reading.