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Airway - Nasopharyngeal airway

Indications

Upper airway obstruction requiring airway manoeuvres

Contraindications (absolute in bold)

Facial or basilar skull fracture suspected

Coagulopathy

Alternatives

Oropharyngeal airway

Laryngeal mask airway

Intubation

Informed consent

Medical emergency

Consent is not required if the patient lacks capacity or is unable to consent

Brief verbal discussion is recommended if the situation allows

Potential complications

Failure to open airway

Pain

Epistaxis

Procedural hygiene

Standard precautions

PPE: non-sterile gloves, surgical mask, protective eyewear or shield

Area

Any

Staff

Procedural clinician

Equipment

Nasopharyngeal airway (sized from tip of patient’s nose to tip of the earlobe)

Water-soluble lubricant

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.

Medication

Nil

Sequence

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

Use 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 60 NPA and average height males a size 70 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).

Peer review

This guideline has been reviewed and approved by the following expert groups:

Emergency Care Institute

Please direct feedback for this procedure to ACI-ECIs@health.nsw.gov.au.

References

Australian Resuscitation Council and New Zealand Resuscitation Council. ANZCOR guideline 11.6 – equipment and techniques in adult advanced life support. Melbourne: Australian Resuscitation Council and New Zealand Resuscitation Council; 2016. 16pp. 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.

Dunn RJ, Borland M, O'Brien D (eds.). The emergency medicine manual. Online ed. Tennyson, SA: Venom Publishing; 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

Roberts K, Whalley H, Bleetman A. The nasopharyngeal airway: dispelling myths and establishing the facts. Emerg Med J. 2005;22(6):394‐396. doi:10.1136/emj.2004.021402

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