The 7th National Audit Project

In this article, Dr Ben Stretch summarises the key finding related to airway management from the 7th National Audit Project (NAP7) of the Royal College of Anaesthetists that looked at Perioperative Cardiac Arrest.

NAP7 collected data on perioperative cardiac arrest cases between 16th June 2021 and 15th June 2022. The report was launched on 17th November 2023 and is available on the RCoA National Audit Projects website, along with related publications. The project began with a baseline survey that highlighted key challenges in modern anaesthetic practice, including an ageing and increasingly co-morbid population, as well as higher rates of patients living with obesity. While distinct from NAP4, the data from NAP7 suggest that airway management has likely become safer over the past decade, despite the surgical population presenting greater anaesthetic challenges.

During the 18-month data collection period for NAP7, 71 out of 881 perioperative cardiac arrests were directly linked to airway complications, making airway complications were second most common complication, with an incidence of 1.7% and accounting for 21.9% of all complications. Chapter 21 of the report, titled “Airway and respiratory complications associated with perioperative cardiac arrest”, provides a detailed analysis of these findings.

All 71 arrests were hypoxic in origin, with contributing factors including failure of primary and rescue airway techniques, displaced tracheostomies, oesophageal intubation, aspiration, and airway haemorrhage. High-risk groups identified in the report included patients living with obesity, individuals with head and neck pathology (accounting for 34 of the 71 cases), and a disproportionately high number of infants under one year old. A single case of aspiration was associated with the use of a supraglottic airway (SGA), which stands in contrast to findings from NAP4. This, along with the significant increase in the use of second-generation SGAs since NAP4, is particularly noteworthy.

Despite advances in both technical and non-technical aspects of airway management, complications still occur, sometimes with catastrophic outcomes. Alarmingly, the survey found that potentially serious airway complications occurred in 8% of cases. Common issues included laryngospasm (38%), failure of the primary airway technique (30%), and aspiration (6.4%). Emergency Front-of-Neck Access (eFONA) was required in approximately 1 in 8,370 cases, with obesity—particularly above a BMI of 35—remaining a significant risk factor. Extremely high BMI (>60) doubled the risk of airway complications compared to a BMI of 25.

Airway-related cardiac arrests predominantly occurred out of hours, despite a consultant anaesthetist being present in over 90% of cases, reflecting the complexity of these emergencies. Some high-risk cases were managed by junior clinicians for training purposes, raising concerns about appropriate allocation of resources and supervision. When one airway technique fails, the likelihood of successful rescue techniques diminishes—a phenomenon termed “composite airway failure.” This highlights the critical importance of a clear, well-structured airway management strategy. The NAP7 report emphasises the value of involving a second anaesthetist in cases with predicted airway difficulty, physiologically challenging airways, or emergencies in remote locations.

Key reccomendations from NAP7

National
▪ Airway managers should be aware of recently published guidance on unrecognised oesophageal intubation as a core component of safe airway management and adhere to it.

Institutional
▪ Infants and neonates should be recognised as a patient group at high risk of airway difficulty, during and after surgery and when critically ill. Departments should make provision for senior and expert airway care for such patients at all times of day and night.
▪ Institutions should ensure that the training facilities and time exist for anaesthetists to establish and maintain skills in eFONA.
▪ Regardless of outcome, all instances where airway management leads to cardiac arrest should be followed by a debriefing and departmental review.

Individual
▪ All anaesthetists should recognise that airway and respiratory management remains a major cause of peri-operative cardiac arrest and engage in education and training that maintains and develops their airway skills, throughout their career.
▪ The airway of patients with obesity should be managed as high risk. This may involve avoidance of general anaesthesia but requires a strategy and consideration of the risks of composite airway failure and short safe apnoea time.
▪ Anaesthetists should treat cases of acute abdomen as high risk for aspiration, assess the extent of that risk and plan airway management accordingly. Each airway manager should decide which elements of rapid sequence induction they wish to use and be prepared to justify their use or omission.
▪ Despite its rarity, anaesthetists need to establish and maintain the lifesaving skills of eFONA and be willing to use them promptly when needed, if a more specifically skilled surgical operator is not immediately available.
▪ Airway managers who are or may be involved in resuscitation of a child who is critically ill should maintain paediatric airway skills and knowledge of methods to prevent and manage hypoxaemia and airway difficulty.
▪ Anaesthetists should be familiar with all the equipment they use and ensure both that anaesthetic circuits are working before use and that all elements of the circuit including the patient interface are compatible.

What are your thoughts on the findings about complications related to airway management identified in NAP7? Why do you think airway-related complications still occur?

In the first part of this course we have explored some of the key concepts of safe airway management. But is there more to airway safety? In the next activity, we will explore the role of Human Factors and Ergonomics, beginning with discussing the case of Mrs Elaine Bromiley, who tragically died as a result of failed airway management.