ACLS Provider: Course

Nasopharyngeal Airway (NPA) Insertion

The nasopharyngeal airway (NPA) is a flexible airway adjunct inserted through the nostril to maintain patency in patients with a partially obstructed upper airway. Unlike oropharyngeal airways, NPAs can be used in semi-conscious or conscious patients who retain a gag reflex, making them especially useful in a range of clinical situations.

Indications

  • Semi-conscious or conscious patients who require airway support.
  • Patients with an intact gag reflex where an OPA is not tolerated.
  • Frequent need for airway suctioning due to secretions.
  • Bridge to more advanced airway management.

Contraindications

  • Suspected basilar skull fracture (e.g., raccoon eyes, Battle’s sign, CSF leakage).
  • Significant nasal trauma or deformity.

Sizing and Preparation

  • Diameter: Choose an NPA slightly smaller than the patient’s nostril.
  • Length: Measure from the tip of the nose to the earlobe or angle of the jaw.
  • Lubrication: Apply water-soluble lubricant generously to the airway before insertion.

Insertion Technique

  1. Position the patient’s head in a neutral position if no cervical spine injury is suspected.
  2. Insert the NPA bevel-first, following the natural curve of the nasal passage.
  3. Advance gently and stop if resistance is met—never force the airway.
  4. If insertion is difficult or unsuccessful, attempt the other nostril.
  5. The flange should rest flush against the nostril when properly seated.

Confirmation of Placement

  • Visible chest rise with ventilations.
  • Unimpeded airflow through the NPA during spontaneous or assisted breathing.
  • Absence of gagging or resistance in a properly sized and placed airway.

Potential Complications

  • Epistaxis: Minimize risk with lubrication and gentle technique.
  • Improper placement: May enter the esophagus or be too short to bypass the tongue.
  • Gagging or discomfort: Indicates possible oversizing or incorrect angle of insertion.

Key Considerations

  • NPAs are ideal when an OPA is contraindicated or poorly tolerated.
  • Use caution in patients with facial trauma or suspected skull fracture.
  • Ensure suction equipment is available in case of bleeding or vomiting.