Airway – Oropharyngeal airway

Procedure, instructions and discussion

Oropharyngeal airway (OPA) for upper airway obstruction and reduced level of consciousness

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Instructions

Indications

• Upper airway obstruction requiring airway manoeuvres

and

• Reduced left of consciousness

Contraindications (ABSOLUTE/relative)

• Nil

Alternatives

• Nasopharyngeal airway (NPA)
• 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
• Vomiting (if gag reflex intact)
• Airway obstruction (if posterior displacement of tongue)
• Aspiration
• Laryngospasm

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 (sniffing position), or
• Neck in neutral position with spinal immobilisation (cervical injury suspected)
• Head-tilt, chin-lift or jaw thrust applied

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

• Oropharyngeal airway (sized from corner of the patient’s mouth to tip of the earlobe)
• Lubricant

Sequence

Insertion

• Open the patient’s mouth with your thumb and index finger
• Insert the inverted airway along the patient’s hard palate
• Advance posteriorly until distal end entering hypopharynx, then rotate 180 degrees
• Use a jaw thrust to aid passage if required
• Advance until the flared external tip is as the oral orifice

Post-procedure care

DOCUMENT PROCEDURE

• Definitive airway management if required

Tips

• Oropharyngeal airways prevent the base of the tongue from obstructing the airway
• When inserting an OPA, the clinician must avoid pushing the tongue into the posterior pharynx
• Too small a device is ineffective, too large a device can press against the epiglottis obstructing the larynx
• Nasopharyngeal or oropharyngeal airways should be considered with all bag-mask ventilation

Discussion

A tongue depressor can be used to move the tongue out of the way and pass the airway (instead of inverted insertion and rotation). This method may be considered with suspected oral or palate injury. It is generally not necessary.

References

• 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/
• Roberts JR, Custalow CB, Thomsen TW. Roberts and Hedges’ clinical procedures in emergency medicine and acute care. 7th ed. Philadelphia, PA: Elsevier; 2019.
• 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
• 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.

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