Airway - Nasopharyngeal airway
Upper airway obstruction requiring airway manoeuvres
Contraindications (absolute in bold)
Facial or basilar skull fracture suspected
Laryngeal mask airway
Consent is not required if the patient lacks capacity or is unable to consent
Brief verbal discussion is recommended if the situation allows
Failure to open airway
PPE: non-sterile gloves, surgical mask, protective eyewear or shield
Nasopharyngeal airway (sized from tip of patient’s nose to tip of the earlobe)
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.
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
Use definitive airway management if required
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
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).
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.
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