EMCrit Podcast 47 – Failure to Plan for Failure: A Discussion of Airway Disasters and the NAP4 Study

Cliff Reid of Resus.Me fame put out an incredible post on NAP4, the audit done on all of the airway complications in Great Britain. It was such a phenomenal post that I got in touch with Cliff and asked if he wanted to come on the podcast to speak about it. He did me one better and got an interview with one of the authors of the Emergency and Critical Care Section.

So in this podcast, we interview Dr. Jonathan Benger, professor of Emergency Medicine with a particular interest in the management of the airway.

Points that came out of the show

  • Mortality is higher in the ED and ICU compared to the operating room. Our patients are sicker, so we must be more diligent in planning
  • Quantitative wave-form ETCO2 should be the standard of care for EVERY ED and ICU intubation
  • Needle cricothyrotomy seems to fail more often than surgical cricothyrotomy
  • Awake intubation was not used when it was indicated
  • Junior resident anesthesiologists were often responding to the ED and ICU
  • There was a failure to plan for failure
  • Obesity figured into a large percentage of the airway disasters
  • Airway operators were not prepared or just did not properly progress to surgical airway

For more from the NAP4

Executive Summary

Full Report (Skip to the EM/ICU Chapter)

How to subscribe to Cliff Reid’s Brand New Podcast

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  1. Minh Le Cong says

    Thanks Scott and Cliff for the interview podcast.
    There are some good take home messages but I would suggest that you have to be careful drawing strong conclusions from an audit such as NAP4. Whilst it is a very praiseworthy effort in the field of airway management research, it does not compare standard techniques /procedures. If anything it compares different practitioners using a technique they call the same name. To conclude that needle cricothyroidotomy is inferior to surgical open cricothyroidotomy based on an audit of uncontrolled techniques by various levels of provider is a big assumption to make. What is the goal of a rescue cricothyroidotomy anyway? To get a cuffed tube into the trachea or to rescue oxygenate ? If it is to rescue oxygenate I have seen video data from Dr Heard’s wet lab in PErth, Australia that needle cric is quicker than open cric(30 secs versus 100 secs) – oxygen via 14G needle cannula into the trachea. Its true that the Seldinger wire kits to convert a needle cric into a cuffed tube in the trachea are slower to use but this misses the point of rescue oxygenation.

    The other point that was not addressed is children needing a surgical airway. Is the suggestion from NAP4 that children have open surgical crics as first line rescue technique? Its easy to say that but how many of us would proceed faced with such a situation? And this gets to the human factors issues of surgical airway management. Its one thing to tell people that they should all pick up a scalpel and do an open cric but in reality it is such a psychological barrier for many doctors to overcome that many simply are unable to and will fall back to what gives them routine success, leading to fixation errors of multiple attempts at laryngscopy etc. does this mean we all need better standardised, well researched surgical airway training? Yes it does and I am sure we are all in agreeance on this point. DOes it mean the only thing we should be teaching and learning is open crics? I do not believe so. Even NAP4 does not draw that conclusion. Needle crics are only a temporising measure, to rescue oxygenate and provide more time to proceed to the next step which might be several options. It is not uncommon that once the hypoxic crisis is addressed with a needle cric, a more careful repeat attempt at laryngoscopy is successful and avoids the possible complications of an open cric. In fact this issue is described in NAP4.
    lets not throw out the baby with the bathwater, folks!

    • says


      Some fantastic points. I would respond, but even more fun would be to tape a show where we debate the issue. Are you game? If not, then I will give written reply. I cannot comment on the peds issue. I never speak about peds, b/c I do not feel I am an expert on the issue. Any readers want to comment on that portion?


  2. Ram says

    Minh, Scott

    great points. I agree that you cannot conclude unequivocally that needle cric is inferior to surgical. I would argue, more importantly, that we will NEVER get that information. The only way to prove this is to complete a RCT comparing some standardized needle technique to surgical cric. With such a rare event and no realistic way to consent to treatment, NAP4 or versions of that study, will be the best we can get. This is even more pronounced in peds, as surgical airway is likely an even more infrequent event.

    I’m not sure I agree with the idea of a small diameter angiocath in the trachea( introduced via a needle ) providing some sort of ventilation in order to to give you a chance at repeated attempts by laryngoscopy. The whole point of diverting your gaze to the neck is that you failed from above. You shouldn’t be going to the neck unless you’ve exhausted attempts from above and you can’t ventilate at all. Simply stated going to the neck means the ship is sinking and you are locked in to doing a rescue surgical airway. At that point I think cutting until you feel the membrane or trachael rings is the easiest thing to do. The goal for me at that point would be to ensure adequate ventilation/oxygenation that will not leave the person with hypoxic brain injury. ie bagging through an ET tube or shiley not an angio cath. I think a stab incision anywhere to get air will work. I have seen ET tubes shoved between trachael rings and not the cric membrane and been functional.

    But what do I know, I’ve never had to do this in real life and you guys have!


    • Minh Le Cong says

      Hi Ram
      I know what you are trying to say. Perhaps in response I’d ask you review the following paper at

      This is published airway research and in Australia is the general approach that the anaesthetic community is increasingly adopting. IN fact it is as a result of similar airway related deaths mentioned in NAP4, within Australia that has led to such airway research and training within my country.

      You must have a simple strategy that gives you small range of options using simple gear and technique.

      Its true that if you have never trained to do a needle cric or trachie then an emergency is not the setting to practice for the first time. The advantage is that you can have multiple attempts with the needle in a short timeframe and using a 14G cannula deliver 200ml/s of oxygen using simple tubing and a 15L/min flow meter…that’s 1L of oxygen in 5 seconds.

      do not live the myth that you can ventilate with the needle airway, its goal is to rescue oxygenate when the SaO2 is 70% as outlined in the research paper.

      read the paper and that might answer some of your questions..if not then let me know what you think afterwards

      • says


        Fantastic paper, but I read the conclusion very differently. We can discuss this during our debate, but it seems this paper is a ringing endorsement of bougie guided cricothyrotomy.

  3. says

    Hi all
    I would say that every doc who does any sort of anesthesia – ED or OT should be drilled in a simple, reliable technique for surgical airway. Imagine a pilot who never trained to land off the normal runway!

    My bias, based on many brown-trouser situations is: scalpel, bougie then a smallish (6 – 6.5) cuffed tube. Use the equipment you know, keep it simple stupid ( the least neurons required the better)

    As for kids – very rare in “normal” kids – the anatomy is the same. Usually less fat. I would not change or have a separate technique for such a rare event. Too much to think about in a moment of crisis. – use the kit you have there. The biggest time delay is in looking for the kit, not using it!

    • Minh Le Cong says

      Thanks Scott and Casey for your comments

      Kids laryngeal anatomy is not the same as an adult. the cricoid cartilage is only partly formed depending upon the age and the membrane is smaller. SOmetimes there is more fat in the neck.
      I agree with keeping things simple and using the gear you have. No argument there. However I think it is only half the story.
      Keeping things simple does not mean in stressful situations people will make the simple decision you hope they will.

      explain why in the Bromiley case three doctors including a surgeon in an elective anaesthetic case failed to perform a surgical airway after multiple failed attempts at intubation and the patient dies from hypoxic brain injury

      explain why as outlined in NAP4, anaesthetists involved in an elective anaesthetic to repair a finger fracture, fail to awaken the patient from a failed intubation and he ultimately dies from an airway exchange catheter that punctured his lung

      Keeping things simple in emergency airway management is only half the story.

      remember the goal of emergency airway management : to deliver oxygen to the lungs. A scalpel is not a guarantee you will achieve that and picking up the scalpel is not a simple act as one might think when you are under extreme stress

  4. says

    Hi Scott et al
    I have managed to track down dr Heard and he is happy to answer some written Qs. I will post it at Broome Docs when I can.
    I’ll let you know if he is up for an interview.
    Interestingly he is a bit critical of some of the recommendations to come out of NAP4. Should make for a lively debate

  5. says

    I look forward to a debate on crichothyrotomy methods. I have seen several cases of medical personnel unfamiliar and/or uncomfortable with procedures hesitating, leading to less than ideal outcomes. I would expect this to be a problem with non-surgical crichothyrotomies, as well. Perhaps that is one of the reasons for the low success rate with the non-surgical crichothyrotomies.

    For capnography, I think that we need to stress that CONTINUOUS waveform capnography is essential. Too many people act as if there is no beneficial information to be obtained from continuing to monitor waveform capnography. I don’t believe that any of you are suggesting check it and forget it, but people hearing/reading this may not realize the benefits of continuing to monitor waveform capnography. I had always assumed that once I connect the waveform capnography, there is no good reason to remove it, but others seem to want to disconnect it as soon as they can.

    Initial waveform capnography does not suture the tube in place, just as an initial chest X-ray does not spot weld the tube in place. These assessments lose any predictive value as soon as they have been completed. Once the patient has been moved, they are no more than nostalgia.

    Excellent podcast by all involved.

    Excellent report by all involved in NAP4. I am still working my way through the full report.


    • says

      great comments! especially regarding the absolute necessity of continuing waveform monitoring so long as the patient has the ET tube in.


  1. […] En viktig punkt, även för er som inte förväntas intubera, är att planera nästa åtgärd om ens plan ej fungerar. En hel del av detta diskuteras av Reuben Strayer samt på emcrit […]

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