Nasopharyngeal Airway Insertion: An Essential Skill for Healthcare Providers

Introduction

The nasopharyngeal airway (NPA) is an essential tool in airway management, particularly in situations where oral airway insertion is not feasible or when the patient’s mouth must remain unobstructed. NPAs are commonly used in prehospital care, emergency rooms, and anesthesia, making it crucial for medical students and healthcare professionals to be proficient in their use. This guide will provide a step-by-step approach to inserting a nasopharyngeal airway, discuss indications, contraindications, and potential complications, and offer tips for optimizing the procedure.

Understanding the Nasopharyngeal Airway

The NPA is a soft, flexible tube inserted through the nostril into the nasopharynx to maintain an open airway. It is typically made from materials like rubber, plastic, or silicone, and comes in various sizes to accommodate different patient demographics, from infants to adults.

Indications

1. Airway Obstruction: The NPA is indicated in patients who have a partially obstructed airway due to tongue relaxation, swelling, or other factors.
2. Seizures: During a seizure, especially in cases where the jaw is clenched, an NPA can provide a clear airway.
3. Unconsciousness: In unconscious patients who are breathing but have a compromised airway, an NPA can maintain patency.
4. Maxillofacial Trauma: When oral access is restricted due to trauma, an NPA can be a viable alternative.

Contraindications

1. Basilar Skull Fracture: An NPA is contraindicated in patients with suspected basilar skull fractures due to the risk of intracranial insertion.
2. Severe Nasal Trauma: Patients with significant nasal injuries should not receive an NPA due to the risk of exacerbating the injury.
3. Coagulopathy: Patients with bleeding disorders or on anticoagulant therapy may be at risk for epistaxis with NPA insertion.
4. Recent Nasal Surgery: Inserting an NPA in patients who have undergone recent nasal surgery can disrupt the surgical site and cause complications.

Sizing the Nasopharyngeal Airway

Proper sizing is critical to ensure the NPA functions effectively and minimizes the risk of complications. The length of the NPA should correspond to the distance from the patient’s nostril to the earlobe or the angle of the jaw. The diameter should be slightly smaller than the patient’s nostril to allow for smooth insertion without causing trauma.

Steps to Size an NPA:

1. Measure the Length: Place the tip of the NPA at the patient’s nostril and align it with the angle of the jaw or the earlobe. The length should match this distance.
2. Choose the Diameter: Select an NPA with a diameter that is slightly smaller than the patient’s nostril. NPAs are typically sized by their French (Fr) gauge, ranging from 12 Fr to 36 Fr.

Inserting the Nasopharyngeal Airway

Once the appropriate size is selected, follow these steps to insert the NPA:

1. Patient Positioning: Position the patient supine with their head in a neutral or slightly extended position. This alignment straightens the nasal passage and facilitates easier insertion.
2. Lubrication: Lubricate the NPA generously with a water-soluble lubricant. Adequate lubrication reduces friction and minimizes the risk of nasal trauma during insertion.
3. Insertion Technique:
   • Hold the NPA at the flange (the widened base of the tube) with the bevel facing the septum (the nasal wall closest to the midline).
   • Gently insert the NPA into the nostril, directing it parallel to the nasal floor. Avoid forcing the NPA upwards, as this can lead to trauma or improper placement.
   • Continue to advance the NPA with a gentle twisting motion, which can help ease the tube past any resistance. The NPA should slide smoothly into the nasopharynx.
4. Confirm Placement: Once the NPA is in place, confirm that it is functioning correctly by assessing the patient’s breathing. The NPA should allow for unimpeded airflow, and you should hear or feel air movement at the external opening.
5. Securing the NPA: If the NPA is to remain in place for an extended period, secure it with a piece of tape or an NPA holder to prevent dislodgement.

Complications and Troubleshooting

While the NPA is generally safe, complications can arise. It is essential to recognize these and know how to address them.

Common Complications:

1. Epistaxis: Nosebleeds are the most common complication due to mucosal trauma during insertion. If bleeding occurs, remove the NPA, apply pressure to the nostrils, and consider using a smaller-sized NPA.
2. Incorrect Placement: Misplacement can lead to airway obstruction or ineffective ventilation. Reassess the patient’s airway and consider alternative methods if the NPA is not functioning as intended.
3. Gagging or Coughing: Stimulation of the gag reflex can occur if the NPA is too long or improperly placed. Reevaluate the size and placement, and adjust as necessary.
4. Airway Resistance: If resistance is encountered during insertion, do not force the NPA. Consider the possibility of an anatomical obstruction or improper angle, and try the other nostril or a different size NPA.

Special Considerations

Pediatric Patients:

• Children have narrower nasal passages and are more prone to airway trauma. Choose an appropriately sized NPA and be particularly gentle during insertion.

Trauma Patients:

• In trauma cases, especially with facial injuries, be cautious of contraindications such as basilar skull fractures. When in doubt, choose an alternative airway management technique.

Anesthesia and Conscious Patients:

• In patients under anesthesia, the insertion is usually easier due to muscle relaxation. However, in conscious patients, the process can be uncomfortable. Consider using topical anesthetics to minimize discomfort.

Alternative Airway Management Options

In cases where an NPA is contraindicated or fails, alternative methods should be considered:

1. Oropharyngeal Airway (OPA): Useful in unconscious patients without a gag reflex. The OPA is inserted into the mouth and holds the tongue away from the airway.
2. Endotracheal Intubation: For more definitive airway control, especially in critically ill or unconscious patients, intubation may be required.
3. Supraglottic Airway Devices: These include tools like the laryngeal mask airway (LMA), which can provide effective ventilation without the need for endotracheal intubation.

Post-Procedure Care

After NPA insertion, monitor the patient for any signs of distress, airway obstruction, or complications. Regularly check the placement and patency of the NPA, especially if the patient is moved or their condition changes.

Monitoring:

• Ensure continuous monitoring of the patient’s respiratory status.
• Watch for signs of hypoxia, such as cyanosis, agitation, or changes in consciousness.
• Regularly assess the NPA for patency and signs of displacement.

Patient Comfort:

• If the NPA is to remain in place for an extended period, consider periodic removal and re-lubrication to prevent mucosal dryness and discomfort.

Documentation:

• Record the size and type of NPA used, the side of insertion, and any complications encountered during the procedure. Also, document the patient’s response to the NPA.

Conclusion

Mastering the technique of nasopharyngeal airway insertion is a vital skill for medical students and healthcare professionals. Understanding the indications, contraindications, and proper insertion techniques ensures patient safety and effective airway management. While the procedure is relatively straightforward, attention to detail is critical to avoiding complications. With practice and adherence to guidelines, healthcare providers can confidently use NPAs to manage patients’ airways in various clinical scenarios.