Why do airway incidents still happen?
Airway management is usually routine and successful. When it goes wrong, failure to oxygenate can cause brain injury or death within minutes, which makes airway incidents among the most serious events in anaesthesia, intensive care and emergency medicine.
The Fourth National Audit Project (NAP4), run by the Royal College of Anaesthetists and the Difficult Airway Society and published in 2011, studied major airway complications across the UK. Events in intensive care and emergency departments were more likely to result in death or brain injury than those in theatres. Recurring themes included poor assessment and planning, failure to use or interpret capnography, persistent attempts at intubation, late calls for help and difficulty with emergency front-of-neck access.
What does 'no trace, wrong place' mean?
Oesophageal intubation is a recognised complication and is not, in itself, negligent. The danger lies in not recognising it. A patient with a tube in the oesophagus receives no ventilation, and good pre-oxygenation can keep saturations normal for several minutes, giving false reassurance before a rapid fall.
Clinical signs are unreliable. Clinicians may believe they saw the tube pass the cords when the view was poor. Misting, chest movement and breath sounds can all occur with an oesophageal tube. International consensus guidance published in 2022 by the Project for Universal Management of Airways and partner airway societies states that a sustained exhaled carbon dioxide trace is needed to confirm tracheal placement. The Royal College of Anaesthetists and the Difficult Airway Society promote this as 'no trace, wrong place'.
| Capnograph finding | What it may mean | Safer response |
|---|---|---|
| Sustained waveform of normal shape over several breaths | Tracheal placement likely | Continue, and recheck after any movement of the patient or tube |
| A few small waveforms that fade away | Possible oesophageal placement, with gastric carbon dioxide washing out | Treat as oesophageal until proven otherwise |
| Flat trace | Oesophageal tube, disconnection, obstruction, equipment fault, or very low pulmonary blood flow | Assume wrong place; remove and oxygenate by another means unless tracheal placement is confirmed immediately |
| Flat trace during cardiac arrest | Effective CPR usually produces a detectable trace | Do not blame the arrest; reassess tube position |
How should you plan an airway before induction?
Most airway emergencies are easier to prevent than to rescue. A structured plan, shared aloud with the team, is one of the strongest defences available.
- Assess: Review previous anaesthetic records and airway alerts. Ask about previous difficulty, snoring, reflux and neck problems. Examine mouth opening, dentition, jaw protrusion, neck movement and the front of the neck. Consider factors that make oxygenation harder, such as obesity, pregnancy and critical illness.
- Plan each stage: Decide your primary technique and the backup at every stage: laryngoscope, supraglottic airway, and how front-of-neck access would be performed. Consider an awake technique if difficulty is predicted.
- Prepare equipment: Check suction, laryngoscopes including a videolaryngoscope, bougie, tubes, supraglottic airways and a front-of-neck access kit. Confirm waveform capnography is connected and working before induction.
- Brief the team: Say the plan aloud, including who will watch the monitor, who will call for help and when. Invite the team to speak up if they see falling saturations or no trace.
- Optimise oxygenation: Pre-oxygenate effectively, position well, and use techniques to extend safe apnoea time in line with current guidance and local practice.
What are the DAS plans for unanticipated difficult intubation?
The Difficult Airway Society published updated guidelines for unanticipated difficult tracheal intubation in adults in 2025. They keep the familiar sequence of Plans A to D while emphasising videolaryngoscopy as a first-line device where available, continuous attention to oxygenation, moving promptly between plans, and making sure the whole team knows the plan. Attempt limits and device recommendations are set out in the guideline itself, so read the current version and your local adaptation rather than relying on memory.
| Plan | Aim | Key principles |
|---|---|---|
| Plan A | Intubate while maintaining oxygenation | Limit laryngoscopy attempts as the guideline sets out; change something meaningful between attempts; declare failure early |
| Plan B | Maintain oxygenation with a supraglottic airway | Use a second-generation device; then stop and think about waking the patient, continuing, or intubating through the device |
| Plan C | Final attempt at face mask oxygenation | If successful, wake the patient where possible; if not, declare can't intubate, can't oxygenate (CICO) |
| Plan D | Emergency front-of-neck access | Proceed without delay using the technique your guideline and department train for, with the whole team ready |
Say each transition aloud: 'Plan A has failed. Moving to Plan B.' Saying 'This is a can't intubate, can't oxygenate situation' tells everyone the situation has changed and helps the operator overcome hesitation. Separate guidance exists for obstetric, critical care, paediatric and extubation settings; use the one that fits your patient.
Human factors: why skilled teams get stuck
Airway emergencies create exactly the conditions in which human performance degrades. A widely taught UK case from 2005, in which a patient died after a can't intubate, can't oxygenate event during routine surgery, showed how experienced clinicians became fixated on intubation, lost track of time, and did not act on cues from nursing staff who had prepared emergency equipment. That case reshaped airway human factors training across the NHS.
- Fixation: the operator focuses on getting the tube in and loses awareness of saturations, time and alternatives.
- Task saturation: one person is trying to do too many things under stress.
- Lost situational awareness: nobody realises how much time has passed or how far saturations have fallen.
- Hierarchy: an operating department practitioner, nurse or junior doctor sees the problem but is not heard or does not feel able to insist.
- Normalisation: poor capnography traces are explained away because monitoring problems are common.
- Unfamiliarity: front-of-neck access kits or videolaryngoscopes the team has not practised with, or an unfamiliar team outside theatres.
What helps is practical: a shared plan, a named person calling out saturations and capnography, cognitive aids such as the DAS algorithms or the Vortex approach on the wall and actually used, regular team simulation including front-of-neck access drills, and a culture in which anyone can say 'I can't see a trace' and be listened to.
When and how should you call for help?
Calling for help is a clinical skill, not an admission of failure. In UK anaesthetic practice early escalation is expected and supported, including calling a consultant out of hours. Doctors new to the NHS sometimes worry that this will be seen as weakness; it will not.
- When difficulty is predicted and you are not confident of managing it alone.
- After a failed first attempt in a patient with risk factors.
- When saturations start to fall despite your interventions.
- As soon as you move from Plan A to Plan B.
- When working outside theatres with an unfamiliar team or equipment.
Registrar, during a third attempt: 'It's fine, I nearly had it. Just one more go.' No help is called.
Registrar, after the second failed attempt: 'I'm declaring failed intubation. Please call the consultant on the emergency line now. Moving to Plan B with a second-generation supraglottic airway. Call out the saturations every 30 seconds.'
When you call, be specific about who you are, where you are, the problem and what you need: 'Anaesthetic registrar, theatre 4, can't intubate in an adult, saturations 85 percent and falling, I need the consultant and the difficult airway trolley now.' Repeated laryngoscopy causes swelling and bleeding that make later attempts harder, so treat the thought 'just one more try' as a cue to move on.
What should you do after an airway incident?
- Stabilise the patient: Secure oxygenation, manage instability and arrange the right level of ongoing care.
- Inform seniors: Tell your consultant and the responsible team, and agree who will speak to the patient and family.
- Be open: Explain what happened, apologise and say what is being done. The professional duty of candour applies to you, and in England the provider has a statutory duty for notifiable safety incidents.
- Document a clear timeline: Record the assessment, the plan, each attempt and device, saturations and capnography, when help was called and arrived, and the outcome. Ensure an airway alert or letter is arranged. Add late entries clearly marked; never alter earlier ones.
- Report and debrief: Complete an incident report, take part in a team debrief, and keep any faulty equipment for inspection.
- Get support and advice: These events are distressing. Talk to your supervisor or clinical lead. If you are asked for a formal statement or contacted by the GMC, seek advice from your defence organisation before responding.
Omar, a specialty doctor covering an emergency list, intubates with a grade 3 view. Two small waveforms appear, then fade. Saturations are 97 percent, so he blames low blood pressure and asks the ODP to check the sampling line. When she says she cannot see a trace, he listens and hears breath sounds. Saturations fall to 70 percent before he removes the tube, oxygenates by mask, and reintubates with a videolaryngoscope, confirming a sustained trace. The patient recovers. In his reflection, Omar does not blame the monitor. He writes that he anchored on a tube he believed he had placed, discounted the clearest evidence and the ODP's warning, and should have removed the tube at once. He now says 'no trace, wrong place' aloud at every intubation and has completed simulation training with his department.
Turning lessons into safer practice
Regulators consider whether a doctor's fitness to practise is currently impaired, looking at insight, remediation and the risk of repetition. In airway cases that may include whether you worked within your competence, followed recognised guidance, called for help appropriately and behaved honestly afterwards. Credible remediation is specific and verified: supervised lists, simulation, feedback from the team and a clear account of what you now do differently. It applies to anaesthesia associates, ODPs and nurses as well as doctors, each within their own role and standards.
Our course Airway Incidents and Escalation in Anaesthesia covers unrecognised oesophageal intubation, airway planning, the DAS approach, human factors, escalation and the steps after an incident, with a guided reflection and remediation plan. It is written for anaesthetists, intensive care and emergency doctors, and anyone who wants to strengthen airway safety, including international graduates becoming familiar with UK practice. It complements, and does not replace, hands-on airway and simulation training.
Frequently asked questions
What is the most common cause of serious airway incidents in anaesthesia?
UK audit work, particularly NAP4, found that serious airway events were most often linked to poor assessment and planning, failure to use or correctly interpret capnography, repeated attempts at intubation, and delays in calling for help or moving to the next plan, rather than to a lack of basic technical skill. Human factors such as fixation and hierarchy are common threads.
How do you confirm tracheal intubation?
A sustained exhaled carbon dioxide waveform on capnography is required to confirm tracheal placement. Seeing the tube pass the cords, misting, chest movement and breath sounds can all be misleading. If there is no sustained trace, assume the tube is in the oesophagus until proven otherwise, and remove it and oxygenate by another means unless placement can be confirmed immediately.
Does a flat capnography trace in cardiac arrest mean the tube is misplaced?
It should be treated as possible oesophageal intubation. Effective CPR usually produces a detectable carbon dioxide trace, so a completely flat trace should not be blamed on the arrest. The Royal College of Anaesthetists and Difficult Airway Society advise reassessing tube position rather than assuming low cardiac output explains it.
What are the DAS Plans A to D?
Plan A is face mask ventilation and tracheal intubation with limited attempts. Plan B is oxygenation through a second-generation supraglottic airway. Plan C is a final attempt at face mask oxygenation, after which you wake the patient if possible. Plan D is emergency front-of-neck access in a can't intubate, can't oxygenate situation. Check the current 2025 DAS guideline for attempt limits.
When should a trainee call the consultant during a difficult airway?
Early. Call when difficulty is predicted and you are not confident, after a failed first attempt in a patient with risk factors, when saturations begin to fall, and as soon as you move from Plan A to Plan B. In UK practice, early escalation is expected and supported at every grade, including out of hours, and is not seen as weakness.
Is oesophageal intubation negligence?
Oesophageal intubation itself is a recognised complication and is not automatically negligent. Failing to recognise and correct it promptly is the serious safety issue. Whether any individual's care fell below the expected standard depends on the facts. If you are involved in an incident, seek advice from your defence organisation and be open and factual throughout.
What should I write in my notes after a difficult airway?
Record a clear timeline: your assessment and plan, each attempt with the device and view, saturations and capnography findings, when help was called and arrived, how oxygenation was maintained, and the outcome. Arrange an airway alert or letter so future teams know about the difficulty. Never alter earlier entries; add clearly marked late entries if needed.
Related courses
Airway Incidents and Escalation in Anaesthesia
This course looks at serious airway incidents in anaesthesia, intensive care and emergency medicine, with a particular focus on unrecognised…
Maternity Care and Fetal Monitoring Concerns
This course teaches safe fetal monitoring in labour, including intermittent auscultation, structured CTG review and escalation, using UK guidance and…
Paramedic Practice: Assessment and Non-Conveyance Decisions
This course teaches a structured approach to assessment and safe decision-making when a paramedic considers discharging a patient on scene or…
Sources and further reading
- Fourth National Audit Project (NAP4): Major complications of airway management in the UK. Royal College of Anaesthetists and Difficult Airway Society.
- Capnography: No Trace = Wrong Place. Royal College of Anaesthetists.
- Difficult Airway Society 2025 guidelines for management of unanticipated difficult tracheal intubation in adults. Difficult Airway Society.
- Recommendations for standards of monitoring during anaesthesia and recovery. Association of Anaesthetists.
- Guidelines for the Provision of Anaesthetic Services. Royal College of Anaesthetists.
- Good Medical Practice (2024). General Medical Council.
Practitioner Insight is an independent education provider. It is not affiliated with or endorsed by the GMC, MPTS, NMC, HCPC, GPhC or any NHS organisation, and this information is not legal advice. If you have been referred to a regulator, speak to your defence organisation, trade union or legal representative.
More guides
CTG Fetal Monitoring and Escalation: Key Lessons for Midwives and Obstetricians
CTG fetal monitoring and escalation for midwives and obstetricians: NICE NG229 essentials, holistic hourly review, fresh eyes, SBAR and maternity lessons.
Non-Conveyance Decisions: A Safe Practice Guide for Paramedics
A safe practice guide to paramedic non-conveyance decisions: structured assessment, high-risk groups, capacity and refusal, safety-netting and documentation.
Safety-Netting Advice: Examples for Emergency and Urgent Care Clinicians
Safety-netting advice examples for emergency and urgent care: what to say, red flags to give, how to check understanding and how to document it.