The lack of a cheap and simple breathing monitor on NHS intensive care wards is causing unnecessary patient deaths, warn doctors.
According to the Royal College of Anaesthetists, using a capnograph may avoid over 70% of breathing-related deaths on UK intensive care wards.
A capnograph can detect problems as soon as they occur and immediately alert staff to intervene.
It is already used almost universally in operating theatres.
It works by detecting carbon dioxide in exhaled breath to confirm that the patient is breathing sufficiently.
But only a quarter of intensive care units in the UK use the device, according to this latest report.
Report author Dr Tim Cook, who is a consultant anaesthetist at the Royal United Hospital in Bath, said: "The single most important change that would save lives is the use of a simple breathing monitor, which would have identified or prevented most of the events that were reported.
"We recommend that a capnograph is used for all patients receiving help with breathing on ICU.
"Greater use of this device will save lives."
He said the introduction of capnography to more ICUs would require "modest cost" and some training of nurses and those doctors who are not familiar with its use.
Patients at highest risk of breathing complications are those with other health problems, such as obesity.
The report found obese patients had double the risk of airway problems when they needed a general anaesthetic compared with non-obese patients.
It monitored all airway complications recorded between 2008 and 2009 in operating theatres, intensive care units and hospital emergency departments throughout the UK.
Of 184 reports of complications, 38 resulted in a death. Sixteen of these deaths occurred while under general anaesthetic in the operating theatre, 18 occurred on intensive care units and four in emergency departments.
A Department of Health spokesperson said: "We welcome this report and would encourage NHS trusts and staff to take note of the recommendations and take any necessary action to ensure high quality, safe patient care."