National patient safety alert – risk associated with adult breathing circuits lacking a patent exhalation route

Summary

This national patient safety alert has been issued by the NHS England National Patient Safety team, in collaboration with the Faculty of Intensive Care Medicine. The alert is directed at organisations caring for patients on invasive and non-invasive breathing circuits who are required to develop local guidance and visual aids for circuit assembly, implement training on specific safety checks, and establish clear communication processes.

All actions should be completed by 12 June 2026.

Content

This alert has been issued in response to the risk of harm from incorrectly assembled breathing circuits lacking proper exhalation routes for patients receiving invasive or non-invasive ventilatory support.

A review by the of the national patient safety databases over a 3-year period identified 102 safety incidents describing the absence of an exhalation route because of incorrect assembly or selection of equipment. As a result the patient could not effectively exhale. 2 patients were reported as peri-arrest when exhalation routes were missed from their breathing circuits. In multiple reports describing the physiological deterioration of a patient, the potential for serious harm was mitigated when staff placed the missing exhalation port into the circuit.

Actions required

Organisations should identify a clinical lead and form a working group to develop local guidance and visual aids for the assembly, connection and reconnection of breathing circuits. The guidance and associated training must include the following recommendations:

1) Before connection to the patient, check the breathing circuit includes an exhalation route, and that there are no obstructions within the circuit

2) Perform the following checks when there is any change in the configuration of any breathing circuit:

• observe the patient, checking chest movement (inspiration and expiration), to ensure patient is ventilating normally, and check flow, volume, pressure, saturations and capnography.
• ensure alarm parameters and volume are set appropriately.
• ensure expiratory vents, ports or valves on NIV masks are not occluded.

Organisations should:

3) Ensure the clinical lead (or deputy) oversees any revision to the local guidance

4) Establish a clear process to ensure all updates to the guidance, checklists or visual aids are communicated to all relevant team members

5) Establish a clear process for communicating any urgent changes to local guidance and practice when, for example, a supply chain disruption means standard consumables are unavailable and replacements are provided.

The Faculty of Intensive Care Medicine (FICM) has published a resource to help in the designing of local guidance and visual aids to support the safe set up of invasive and non-invasive breathing circuits. This can be used as a template for organisations to produce local guidance.