The Art of The Nasopharyngeal Airway

I would surely rank the nasopharyngeal airway (NPA) as one of the most under-rated / under-utilized pieces of equipment in the EMT bag of tricks. They’re useful, simple and versatile. As a group, we tend to do a pretty good job oxygenating our patients, but I think we drop the ball on BLS airway adjuncts.

Most of our unresponsive or semi-responsive patients should be arriving at the ER with an NPA in place. If you’re bagging a patient they should have one … maybe two NPAs in place.

They’re fast, they’re friendly, they work much better on the semi-conscious and they don’t stimulate the gag reflex quite like their cousin the oropharyngeal airway. They also stay in place better, leaving the mouth open for examination and advanced airway techniques.

I’ve often had EMTs explain that they didn’t drop a basic airway adjunct because they knew I was right around the corner and I’d be intubating. That’s a poor excuse. When I arrive on scene I’d like to see that the EMT at the head has managed the BLS airway aggressively.

So let’s bone up on our NPA skills. Once you’re comfortable with these little beauties, they only take a few seconds to drop. You don’t need to make it a big production. Grab the right size, squirt a clump of KY on the end and go.

So let’s break it down and make you an NPA, quick draw, master.

1) Know where they are kept.

That goes for the kit and the ambulance. I know this sounds painfully obvious and hopefully it is. If you can visualize exactly where the NPAs are in your kit and your cabinet right now you’re golden. But let’s face it … that’s not always the case.

Sometimes I ask for an NPA and my partner needs to fumble and unzip and peek here and there. “They aren’t in the airway roll brau. They’re on the side of the airway pouch on the … no … in the big kit … on the … Just give it here.”

Know where all the airway stuff is kept. Airway and AED are two items that you want to be able to access without looking. Those are your quick draw items. A gunfighter doesn’t need to look down to see which hip he’s wearing his gun on. Neither should you.

2) Grab the right size.

Your EMT textbook might have explained that the proper way to measure is from the tip of the nose to the ear lobe. True. But you can grab the right size on the first try most of the time with this rule;

Big adults – grab the 8-9mm (24-27 french). Regular sized adults get a 7-8mm (21-24 french). Small adults get a 6-7mm (18-21 french). Kids start at 5mm and work down. When deciding if a patient is “big” or “regular” use their height as a guide, not their weight. Patient height is the most accurate predictor of correct NPA sizing.

This rule goes for all airway devices including OPA’s, Combi-tubes and King tubes.

I’d like to see the French go away. (The scale not the people.) (No … seriously, I’m a huge fan of the Tour De France) The French Scale System is even more complicated than the American measuring system and that’s not an easy feat. The metric measurements are just easier. But if your NPAs are in the French scale … you’ll need to learn it.

We tend to undersized our airway adjuncts. I’m not sure why. I think it starts in EMT school when we learn that the smaller NPAs go in the mannequin head easier. When faced with a real live nare we tend to opt for the smallest reasonable size.

Don’t do it. You’ll end up obstructing more usable nasal passage space than you create. Grab the correct size based on the sizing recommendations above.

3) Lube is your friend, but time is not.

That little package of lubricant does help these things go in faster and it reduces damage to the nasal mucosa but don’t waste too much time coating the NPA with a shinny sheen of lube. Tear open the packet, squirt a clump of lube on the lower half of the NPA and get on with it.

The NPA doesn’t need a full, even, double coat of lubrication Bob Vila, and it doesn’t need a Swedsh massage either. It needs to get sunk it the nasal passage and you need to get on with managing the airway.

4.) Don’t worry to much about the bevel.

In EMT class they probably made a big deal about placing the bevel toward the septum. That is the preferred insertion technique, but nobody has ever really been able to convincingly explain to me why that is. Note that most NPAs are designed to be inserted in the right nostril. (If you follow the bevel rule.) But we also tell you to pick the largest nare.

So which takes precedence? Should we never use the left nare regardless of how tiny the right one might look? Or perhaps insert the NPA backwards? Do neither. Insert it in the largest nare with the curve of the NPA oriented toward the mouth and forget about the bevel.

5.) Back and forth, back and forth, they DOWN.

Some folks wiggle that thing back and forth like they’re trying to start a fire or something. Take it easy boy scout. Yes we taught you to use a gentle back and forth motion on the NPA as you insert it, but you don’t need to over-do it. Once you reach the mid-point of the NPA you should be able to just sink it. And your patient will thank you for it later.

The wiggling may facilitate the advance of the device but it isn’t terribly comfortable on the patients nose. And speaking of down. For the record these things aren’t going up the patient’s nose. They go strait back in to the nasal cavity and turn downward toward the posterior pharynx.


And there you have it. 10 seconds to help secure the airway and then move on.

It’s worth noting that there are some potential complications to NPA use. They are more likely after prolonged use and include:

  • Mucosal irritation
  • Sinusitis
  • Retropharyngeal ulcers
  • Temporary vocal cord paralysis
  • Temporary deafness

There have been two documented case of the NPA being inserted into the cranial vault after massive maxilo-facial trauma. The NPA should be avoided in patients with significant head and face trauma. Minor facial trauma is not a contraindication to NPA use.

Don’t let that list of complications go and scare you off. The NPA is a safe and useful tool. It stays in the airway bag far too often when the patient could benefit from its use. But not anymore … right? Right.

Now it’s your turn: Do you agree that the NPA is under-utilized? What has your experience been with the device. What advice would you give care givers who are unfamiliar with it? Leave a comment and let everyone know your take on the topic.

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  1. I would say both the NPA and the OPA is under used. Many basics have become so reliant on paramedics that they forget to use their basic skills.

  2. Steve Whitehead says:

    Drew, I have seen that same dynamic. Even if the paramedic is right over your shoulder, you should be using BLS airways. I like to begin an intubation with a well prepped airway.

    If the OPA is in, I’ll keep it handy to use as a bite block after intubation. If I have to back off of a first attempt and hyperventilate, I want an NPA already dropped (or two) and an OPA close by to reinsert.

    Airway is a foundational BLS skill and we should be using all the tools in the toolbox. Thanks for your input.

  3. I have lost count of the amount of times that I have arrived on scene to be told that the patient wouldn’t tolerate an OPA, so they have just gone with BVM without any adjunct, and not even considered NPA.

    Personally, I love the NPA, especially in prolonged seizures etc.

    Another great post Steve!


  4. I am a believer. We had a patient that as we put him on the cot. Go unresponsive. spo2. Went to 68. He still had a gag reflex. Dropped a npa in. Started bagging. He was back in no time. My 86 who is also a basic. We love em. We use them quite often.

  5. Medtech21 says:

    I dont think I have ever seen either used in the field unless I was the one using one, and for the same reason mentioned in the article. People assume that because there is a Medic there, intubation will be underway and there is no need for one. But if the pt isnt intubated for 5 or so minutes, that is 5 minutes of poor ventilation. Also when the pt becomes responsive again, some will actually tolerate the NPA for quite some time, Ive even had people talk with one in. In the case of an OPA they have to come out fairly quickly. I go with NPA over OPA almost regularly.

  6. Steve Whitehead says:

    I’m glad to hear we have so many believers.

    @ Medic999 I think there’s more of a natural resistance to the idea of inserting something in the patient’s nose. It seems more invasive. Interesting that this is so universal.

    @ Medic322 Nice job. Thanks for the contribution.

    @Medtech21 I agree with you completely. There are some clear advantages to going with the NPA.

  7. Steve: I’m right there with ya! The NPA had always been my BLS airway of choice… until I moved to Seattle. No Nasal trumpets allowed for basics!

    From and the “Ask the Doc” section:

    QUESTION: Can EMTs use nasopharyngeal airways in King County? — Shawn

    ANSWER: Thank you for your question. Currently, No…the only approved airway adjunct for BLS (in King County) is an OP airway (as needed to maintain a patent airway). — Mike Helbock, M.I.C.P., NREMT-P

    Arrrggghhh! It makes me crazy.

    Luckily, I’m doing my ALS clinicals in a different county, and I was able to sink several NPAs in the past few weeks…

  8. Steve Whitehead says:

    Wow Medic22. I had no idea. I never would have guessed that some systems would make the NPA an ALS intervention.

    It must be one of those bad ideas that stick around for a long time.

    I hope you’ll continue to work to improve the protocol even though you’ve moved on.

  9. First time i went for an NPA on an unconcious overdose patient. Nowhere to be found in the bag. Guess that’s what you get in the volley service, hit and miss, some stock it, some dont. I now keep at least 2 in my jump jacket all the time.

  10. Steve Whitehead says:

    Glad to hear you found a work-around solution Rob but it sounds like there may be some operational issues at your service that would be worth addressing.

    If you meet resistance you might start by telling everyone about the dead AED battery that cost the Chicago Fire Department 3.2 million dollars.

    Let us know how it goes.

  11. Loved the article. It is true that people are so hesitant about putting in an NPA due to the perceived pain, etc. Many of these misconceptions are made worse by providers that have never even put one in.
    I personally love them. You can still place an ALS or BLS airway (ET, King, CombiTube, LMA) with it in place without removal and it is there as a nice backup. I carry a few in my kit and have used them numerous times.
    I start our EMT-B airway class by putting an NPA in myself for the class to see. I then allow the students to try one on themselves or on each other under supervision to learn the right way to do it.
    That alone has made them more comfortable putting them in on real patients.

  12. We do a lot of narcotic ODs and I always drop an NPA in before ventilating. With opiate ODs, if the EMT can manage the airway, the medic can focus on getting a line to give narcan and avoid having to use an advanced airway at all.

  13. As a EMT and Seizure Patient I have had a NPA put in by emts a few times, and I myself have found in alot of cases around here the “fakers” or polite term attention secures— when they pretend to be unconcious or being ill and some people have actually mastered this to the point it can be hard to tell, I give them a nice but fair warning if they don’t wake up or come around by the time we reach the er they are going to have more tubes sticking out of them then they know what to do with, staring with a Npa (as soon as i mention putting a tube down a “Patients” nose I suspect of “pretending” its amazing how fast some of them come around….:) not a a nice trick but it works and Don’t get me wrong I have had some people that “Fake” being ill , I will put NPA down and they tolerate it…!!! Somtimes a small Grimac from them but its amazing how much people will take when they have mental problems, When asked in the ER by the DR why my Patient has a NPA I just respond, I needed to secure the airway they have been having “Pseudo-seizures ” (even thought these are not fake seizures, it is still a mental thing), but I’m taling about the people who actually do… fake being sick breath holding etc…..

  14. I’m not an EMT but I go to a tech school, and I take EMS. In my opinion the NPA is a better choice due to the gag reflex that can be triggered with the OPA. I wouldn’t really use the OPA as an EMT, but I do have a question. How do the OPA and NPA make a difference when using a mask? What difference is there with or without the airway adjuncts?

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  16. I’m a CRNA and started using NPA’s for sedated patients. However we don’t stock premade NPA’s, so I use an cuffless ETT, cut to size. Hooks up to our ETCO2 as well. Awesome and underused tool!

  17. In EMT class they probably made a big deal about placing the bevel toward the septum. That is the preferred insertion technique, but nobody has ever really been able to convincingly explain to me why that is..

    Delete that paragraph, They teach it for a reason. look inside your nose, look at the NPA. notice the beveled edge and notice the smooth round end opposite the bevel edge. notice the lateral side of the nasal passages contains WHAT? and the medial side contains WHAT?…

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  34. Andrew Kelley Przepioski says:

    I was just talking to a friend about inserting NPAs.

    In my experience, most adults (and mannequins) are about a size 32 Fr. This will be the correct size if you are measuring from the tip of the nose to the earlobe (or tragus). Some people will question “will that fit” when they see me select that size and measure it, but then will see that I’ll have no problems inserting it. The patients will have noticeably better compliance during bag-mask ventilation. This has lead me to believe that most adults are around size 32 Fr and my go to size before I measure it by their face.

    On scene for a call, I was given a size 22 Fr for an average height geriatric female probably about 5’5″ and near 90 kg. I immediately felt like it was too small. I still measured it from the tip of their nose towards their earlobe (or tragus) and the 22 didn’t even get close to their ear. We ended up using just an OPA alone on the patient.

    I was telling my friend about my experience with using larger size NPAs and was going to reference this, but noticed that you recommended smaller sizes.

    24-27 Fr Big
    21-24 Fr Regular
    18-21 Fr Small
    <=15 Fr Pediatric

    I was shocked to see this.

    Since you wrote this about half a decade ago, I wonder if your experience and thoughts about NPAs have changed. Have you continued to use these small NPAs? Do you feel like the NPAs I use are too big? Do you feel that measuring from the tip of the nose to the earlobe (or tragus) is just as good predictor of size as looking at the patient's height (it looks like the study you shared compared height to using the patient's finger tip).

    I was taught that too large of an NPA could just end up in the vallecula or push the epiglottis over the trachea. I wonder if these concerns are legit?

    The other thing I kinda find funny is the emphasis and debates on how to insert an NPA when there is resistance. I have never once had any difficulty inserting an NPA. EMT school made it seem like there was gonna be resistance or difficulty, but I expect that this is somewhat uncommon. If you add which way the bevel faces, I have heard people debate about whether it is OK to alter the NPA by cutting the tip or if it is OK to insert it upside down and rotate it. There is a fear that if you alter it, you are not certified to do that, haha! Whatever. If you insert it upside down and rotate it (or don't rotate it), it might kink when it bends in the nose. I guess that is possible. Meh.

    I think the ONLY issue I believe with the bevel is if it'll lacerate the Kiesselbach's plexus or Woodruff's plexus with Kiesselbach's plexus be the most common to lacerate. I believe the bevel is designed to avoid lacerating that and ease of insertion. This is talked about Management of Emergency Airway 3rd Edition in regard to nasal intubations rather NPA insertion, but same concept can be applied I believe. The bevel shouldn't be occluded regardless of which way the bevel faces. I like your recommendation with facing it down towards the mouth.

  35. Andrew Kelley Przepioski says:

    “Kiesselbach’s plexus (Little’s area) is a very vascular area located on the anterior aspect of the septum in each nostril. Epistaxis most often originates from this area. During the act of inserting a nasal trumpet or a nasotracheal tube, it is generally recommended that the device be inserted in the nostril such that the leading edge of the bevel (the pointed tip) is away from the septum. The goal is to minimize the chances of trauma and bleeding from this very vascular area. This means that the device is inserted “upside down” in the left nostril and rotated 180 degrees after the tip has proceeded beyond the cartilaginous septum. Although some authors have recommended the opposite (i.e., that the bevel tip approximate the nasal septum to minimize the risk of damage and bleeding from the turbinates), the bevel away from the septum approach makes more sense and is the recommended method.”

    Pg 38 of Manual of Emergency Airway Management 3rd Edition

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  7. […] What do all these handy-dandy items give you? It gives you just the essentials to treat yourself or your buddy if you aren’t near or can’t make it to medical facilities. You have exam gloves, a tourniquet, a nasopharyngeal airway tube and a bandage. The two most important items I see are the tourniquet and the bandage. You won’t be using the airway tube on yourself, and without training probably won’t use that on anyone else either. The airway tube is designed to clear the airway in an unconscious person so that their tongue doesn’t cause them to suffocate. If you are interested, I found some instructions for using this here. […]

  8. […] what that entails.  Yesterday, we learned how to properly bandage a head wound and insert an NPA (Nasopharyngeal Airway) into a dummy’s head.  Today we are working on tourniquets and body wounds.  It’s […]

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