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.

Related Articles:

Get Anyone To Go With You To The Hospital

Six Techniques to Nail The IV Every Time

EMT Skill: Observation

 

 

Remembering The Glasgow Coma Score

Comments

  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!

    Thanks.

  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 EMSonline.net 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.

    http://theemtspot.com/2009/10/29/why-do-bad-ideas-stick-around/

    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.

    http://thinksafe.wordpress.com/2009/10/13/didnt-change-your-aeds-batteries-that-will-be-3-2-million-death-settlement-please/

    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?

  15. Ensure that you back up any vital data prior to formatting.
    This article describes how you can put your HDTV
    to best use by watching not only your movies, but also your
    photos on it. There are also Mini – SD and Micro – SD cards (mainly used in cellular phones) that can
    be accessed by a regular SD card reader with a simple SD card adapter.

  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?…

  18. Aside from that, interview former patients to obtain first-hand insight into a particular
    cosmetic surgeon’s methods, approach, and techniques to plastic surgery.

    An experienced plastic surgeon can ensure you appealing aesthetic results with the
    help of innovative body contouring procedures.
    There is one error: the sentence “The heir who wins the windfall will be the one who finds the.

  19. One function of the bustle and the hoopskirt
    was to make the waist look smaller and to enhance the bust.
    Dress up in peacock blue, soft pinks and bright orange sexiest
    colours of this season. You will be excited
    watching your kids in pastel tones especially when summer comes.

  20. Yes, fashion trends are referential and recurring, but at the same time new ones pop up, allowing us to visually reflect the
    world around us. Readers may refer to a related article entitled The Best Fashion Merchandising Degree Schools in the U.
    Being a model requires more than just being a pretty
    face.

  21. In a time of paints available on the school bus job twice.
    If you’re cooling, or maybe to do home remodeling project, I only got three days ago to negotiate a fair price and value, and are thus
    a specialist is the financial matters.

  22. It should clearly explain contractor the information needed that will save time and expense.
    It s simply amazing how frequently contractors answer the fourth quarter for the names of the elements
    from entering the foundation to roofing systems to be done to a
    circuit. However, if they just have a website. Accountants passed the
    certification board to make the best contractor available in specific situations, such as Joe Hall Roofing Residential Roofing
    Contractors Repair are the hottest new construction.

  23. Various other resources have echoed that sentiment to WWD
    assuming the modification is happening to permit administration to position a greater emphasis
    on Bendel’s branded bags, style add-ons, fashion jewellery, cosmetic makeup
    products and tour accessories, small leather-based and locks goods and
    home fragrances.

  24. Something as simple as your stance will be tweaked and corrected by your
    trainers in Thailand. Kicking lessons is the act of impelling a ball through striking it with your feet.

    Laura Eggers operates the website a travel guide to Southern California Beaches from Santa Barbara to San Diego.
    The destructive attitude and misbehavior in the kids
    at growing age can easily be controlled. Summer can be focused on sports, music, games, horseback
    riding, archery, golf, swimming, boating, nature life,
    crafts, dance, or any variety of activities.
    As a parent you need real information and tips to help you decide whether it is the best program for you troubled teen. Killing Curtis
    at this point in the quest seems to doom the monorail.
    It may not make sense to think about a summer job
    right now, since school is still in session, but
    you need to think about it. Here’s the question: do we really think they will stop there.
    If you can find wisdom in the way a violin is tuned, that same method may apply to the way
    an annual report is written.

  25. Most people who get a tattoo for the first time are afraid
    that they will get bored of it in the future and
    will end up regretting their decision. You will be surprised by the good
    results you get if you have never tested a professional spray tan before.
    This can be accomplished with some diligent practice under the supervision of a professional expert.

    The shade lasts for a maximum of four to five days. Wearing
    a broad spectrum sunscreen of at least SPF 15 all the time and reapplying every 4 hours is becoming more and more important.
    JC: Heidi Klum, Kim Kardashian, Christina Milian, too many
    to mention. Check your moisturizer and other skin products to make sure they are devoid of this compound.
    These are most suitable for dry skin since the formulation is thick and enriched with moisturizers.
    Recently the spray tanning products are delivered using can which enclosed with latest tanning technology and because of
    the people. During the winter months our skin lightens from the lack of vitamin D that the sun provides for us naturally.

  26. If you can get past the smell, and don’t mind reapplying often, you’ll find
    that for its price, it offers an unbelievably great
    color. During the 20th century, labor began to change and more of it started to take place indoors.
    Sun lab Inc is one of the many companies that have come out with tanning
    solutions for the general public.

  27. As far as the contrast is not that absurd or simply unpleasing on the eye, you can combine several colors as you require.

    In fact, drain problems also occurs during heavy continuous rains or storms.
    Read the easy instructions for making narrow hallways beautiful, a
    cunning home improvement project for women in smaller homes.

  28. Or, those who are trying to sell their homes may need help with home staging, a service most interior decorators offer.
    When executed properly, it can build your websites exposure,
    increase your traffic and improve your conversion rate.
    It’s where promotion is integrated with social network profiles
    where they could put up your brand, company or picture.

  29. There are many ways to reach a goal, and, a better, more motivated
    and more skilled group of individuals will be able to transform
    any space, to bring it to life in better, more interesting
    ways. The roof is an important unit of a house; it helps provide
    safety and comfort to a home’s occupants. Green roofs are types of roofs which contain moss,
    grass, and other kinds of plants growing on the surface.

Trackbacks

  1. [...] Here When You’re Ready To Head Back To The Home Page Previous Post: The Art of The Nasopharyngeal Airway [...]

  2. [...] The Art of The Nasopharangeal Airway. I was initially reluctant to put a skills category on the site. I thought skills would be a [...]

  3. [...] The Art of The Nasopharyngeal Airway [...]

  4. [...] The Art of The Nasopharyngeal Airway [...]

  5. [...] [1] The Art of The Nasopharyngeal Airway The EMT Spot by Steve Whitehead Article [...]

  6. [...] The Art of The Nasopharyngeal Airway [...]

  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. […]

Speak Your Mind