Airway – Nasopharyngeal airway

Procedure, instructions and discussion

Nasopharyngeal airway (NPA) for upper airway obstruction (partial or complete)

Detailed written instructions and explanation are available in our Free App (iOS and Android). This video is hot off the press and we want your help improving it. Drop us a line with any suggestions

Instructions

Indications

• Upper airway obstruction requiring airway manoeuvres

Contraindications (ABSOLUTE/relative)

• Facial or basilar skull fracture suspected
• Coagulopathy

Alternatives

• Oropharyngeal airway (OPA)
• Supraglottic Airway Device intubation (SAD, LMA)
• Intubation

Informed consent

NOT REQUIRED

• Consent is not required.
• This is an emergency procedure to save a life

Potential complications

• Failure to open airway
• Pain
• Epistaxis

Infection control

• Standard precautions
• PPE: non-sterile gloves, N95 mask, protective eyewear or shield

Area

• Any

Staff

• Procedural clinician

Positioning

• Neck flexion with atlanto-occipital extension (head tilt chin lift into sniffing position)

or

• Neck in neutral position with spinal immobilisation (jaw thrust applied – cervical injury suspected)

In adults the sniffing position is achieved by elevating head approximately 10cm while tilting the head posteriorly. This achieves horizontal alignment of the sternum and external auditory meatus. Small children do not require head lift and infants will require slight elevation of the shoulders due to a relatively large occiput.

Equipment

• Nasopharyngeal airway (sized from tip of patient’s nose to tip of the earlobe)
• Water-soluble lubricant

Sequence

Insertion

• Lubricate the airway prior to insertion
• Insert into the right naris with the bevel facing the septum
• Advance posteriorly towards the occiput along the floor of the nasal passage
• Rotate airway if resistance is encountered
• Advance until the flared external tip is as the nasal orifice

Post-procedure care

DOCUMENT PROCEDURE

• Definitive airway management if required

Tips

• Nasopharyngeal airways prevent the base of the tongue from obstructing the airway
• NPA length measured at nasal endoscopy correlates with subject height, independent of sex
• Average height females require a size 6.0 mm NPA and average height males a size 7.0 mm NPA
• The floor of the naris inclines in a caudad orientation at approximately 15 degrees from horizontal
• Nasopharyngeal or oropharyngeal airways should be considered with all bag-mask ventilation

Discussion

Two case reports involve inadvertent intracranial placement of a nasopharyngeal airway in patients with basal skull fractures. In the presence of a known or suspected basal skull fracture, an oral airway is preferred, but if this is not possible and the airway is obstructed, gentle insertion of a nasopharyngeal airway may be life-saving (i.e. the benefits may far outweigh the risks).

References

• Roberts K, Whalley H, Bleetman A. The nasopharyngeal airway: dispelling myths and establishing the facts. Emerg Med J. 2005 Jun;22(6):394-6. 
• Guildner CW. Resuscitation – opening the airway. A comparative study of techniques for opening an airway obstructed by the tongue. JACEP. 1976 Aug;5(8):588-90.
• Australian Resuscitation Council and New Zealand Resuscitation Council. ANZCOR guideline 4 – airway. Melbourne: Australian Resuscitation Council and New Zealand Resuscitation Council; 2016. 7pp. Available from https://resus.org.au/guidelines/
• Wittels KA. Basic airway management in adults. In: UpToDate. Waltham (MA): UpToDate. 2019 Sept 17. Retrieved March 2019. Available from: https://www.uptodate.com/contents/basic-airway-management-in-adults

The App