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Towards safer airway management in the critically ill: lessons from National Audit Project 4


National Audit Project 4 (NAP4) highlighted the need to improve airway management in ICUs and key recommendations were the continuous use of end-tidal carbon dioxide (ETCO2) monitoring, pre-intubation checklists and difficult airway trolleys [1]. This complete cycle audit aimed to quantify the current state of airway management on our ICU and the effectiveness of implementing the NAP4 recommendations.


Data collection was carried out prospectively for both phases and included documentation of intubation, use of ETCO2 and the incidence of serious adverse events (SAEs). The contents of the intubation boxes were compared against the Difficult Airway Society (DAS) guidelines [2]. The re-audit was carried out 6 months following the introduction of a pre-intubation checklist, a documentation sticker, a difficult airway trolley and standardization of the basic bedside airway boxes with a checklist of contents. A training program in airway management for all ICU staff was also introduced.


The baseline characteristics of both groups were similar. The initial audit included 45 patients and the re-audit 58 patients. In the initial audit 19% of patients had accurate documentation of intubation with the use of ETCO2. The continuous use of ETCO2 was 80%. Bedside airway boxes did not contain a checklist of standardized equipment. A difficult airway trolley was not located on the ICU. Following introduction of the changes described, a significant improvement in the use of ETCO2 to confirm intubation (46% vs. 19%, P < 0.01) and continuous use of ETCO2 monitoring (100% vs. 80% P ≤0.0004) was observed. The use of the preintubation checklist (7%) and stickers (11%) was poor. All bedside boxes had a checklist and the required equipment. A difficult airway trolley is located on the ICU with an equipment list and DAS algorithm attached. No SAEs were recorded in either phase.


Serious airway complications are rare. Safer airway management is essential in the ICU to prevent morbidity and mortality. This audit demonstrated that simple measures in conjunction with a structured training program can help to improve the safety of airway management in critically ill patients. Further work is required to improve compliance with the pre-intubation checklist alongside a continued education program.


  1. 1.

    The Royal College of Anaesthetists[]

  2. 2.

    Difficult Airway Society Equipment List[]

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Correspondence to N Santana-Vaz.

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Santana-Vaz, N., Tallowin, S., Lewis, H. et al. Towards safer airway management in the critically ill: lessons from National Audit Project 4. Crit Care 17, P155 (2013).

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  • Airway Management
  • Difficult Airway
  • Continue Education
  • Require Equipment
  • Continue Education Program