Edited by Tim Cook, M.D., Nick Woodall, M.D., and Chris Frerk, M.D. London, The Royal College of Anaesthetists, 2011. Pages: 220. No price available; information available at http://www.rcoa.ac.uk/nap4.

Expertise in airway management is a critical skill set for an anesthesiologist. We train for years to be competent and facile with multiple different airway devices and develop comprehensive airway management plans. Despite this intensive training, failed airway management occurs, and is a significant source of anesthesia-related patient morbidity and mortality. In fact, “cannot intubate, cannot ventilate” scenarios account for approximately 25% of all anesthesia-related deaths. The 4th National Audit Project of the Royal College of Anaesthetists and The Difficult Airway Society: Major Complications of Airway Management in the United Kingdom: Report and Findings  is a prospective study designed to accurately define the types of airway devices used and incidence of airway complications in the United Kingdom. The goal of the report is to interpret these data to make recommendations to improve patient safety during airway management.

The contributors and reviewers of this report represent a distinguished group of experts from the Royal College of Anesthetists, The Difficult Airway Society, the Association of Pediatric Anesthetists, the National Patient Safety Agency, the Association of Anesthetists of Great Britain and Ireland, the Intensive Care Society, and the College of Emergency Medicine. The breadth and depth of expertise on the 4th National Audit Project  enabled the panel to review the data to reinforce existing knowledge, identify new information, and, most importantly, provide expert opinion and recommendations for preventing airway complications for future patients.

The 4th National Audit Project  is well organized, with three distinct sections. Section 1 is a description of the project and quantitative analysis of the gathered data. The report impressively succeeds in its goals of determining the types and frequency of airway devices that are used in the United Kingdom as well as the incidence of major airway complications that lead to significant patient morbidity and mortality. The report, admittedly, recognizes that they likely underestimate the incidence of significant airway complications. Section 2 is a clinical review of 186 cases that were reported. The chapters in this section are organized by phase of anesthesia, location of airway complication, and airway management technique. Each chapter is written to stand alone but, when relevant, cross references are available. They include a brief review of the quantitative analysis, a relevant and high-yield literature review, and a broad review of the cases, and conclude with a discussion of the pertinent clinical themes that were identified and recommendations from the expert panel. The chapters are highlighted by detailed case reports that are typical of the complications related to anesthetic phase, location, or airway device. Section 3 is a summary and overview of the learning points and recommendations from the expert panel. This includes checklists and algorithms for intubation in remote locations, endotracheal tube or tracheostomy displacement, and proforma management plan for potential intubations in the intensive care unit.

It is important to recognize that 4th National Audit Project  is not a textbook on airway management. The panel does not provide recommendations or instructions for a provider to improve their airway management skills. The reports states that it does not support or condemn specific airway management techniques. The information presented in this report is relevant to senior trainees and attending anesthesiologists who will appreciate the value and insight gained from another practitioner's experiences. The 4th National Audit Project of the Royal College of Anaesthetists and The Difficult Airway Society: Major Complications of Airway Management in the United Kingdom: Report and Findings  undertook a challenging task to identify, analyze, and describe this major source of anesthesia-related morbidity and mortality. The report succeeded in its goal and identified clinical themes that can help senior trainees recognize potentially dangerous situations and reinforce an attending anesthesiologist's knowledge to improve patient care. As the editors state, the goal of our profession “should be to reduce serious complications of airway management to zero.”