A nasopharyngeal airway (NPA), often called a nasal trumpet, is a soft, flexible tube inserted through the nose to secure an open air passage in the upper airway. This airway adjunct bypasses obstructions caused by the tongue or soft tissues relaxing and falling back against the pharyngeal wall, common in patients with decreased consciousness. The hollow design creates a clear channel for airflow from the nostril into the posterior pharynx. Because the NPA rests behind the tongue, it is useful for patients who are semi-conscious or unconscious but still have an intact gag reflex, where an oral airway device might trigger vomiting.
Determining Need, Contraindications, and Sizing
The decision to use an NPA is based on the patient’s need for airway support combined with their level of consciousness. The device is indicated for patients who require an airway adjunct but may not tolerate an oropharyngeal airway due to an active gag reflex. It is also helpful when the patient’s mouth cannot be easily opened, such as in cases of trismus (lockjaw) or jaw injury. The NPA helps maintain a patent airway and can serve as a temporary measure before a more secure airway, like an endotracheal tube, is placed.
The use of an NPA carries significant safety warnings, particularly concerning facial trauma. It is absolutely contraindicated in patients with severe facial trauma, especially those with suspected basilar skull fractures. Inserting the NPA risks misdirection of the tube through the cribriform plate and into the cranial cavity. Relative contraindications include nasal deformities, large nasal polyps, or a history of coagulopathy (bleeding disorder), as these increase the risk of severe nosebleeds (epistaxis) during insertion.
Proper sizing is necessary for the safety and effectiveness of the device. The correct length is estimated by measuring the NPA from the tip of the patient’s nose to the tragus of their ear. If the NPA is too long, it may stimulate the gag reflex, potentially causing vomiting and aspiration. A tube that is too short will not effectively bypass the airway obstruction. The diameter should be no wider than the patient’s smallest nostril or the diameter of their little finger, allowing it to pass without causing excessive trauma or blanching of the skin when the flange is seated.
Step-by-Step Insertion Technique
Before insertion, the patient should be positioned to optimize the airway passage, typically supine with the head in a neutral or slightly “sniffing” position, unless a cervical spine injury is suspected. The chosen NPA must be generously coated with a water-soluble lubricant along its entire length to minimize friction and reduce damage to the delicate nasal mucosa. This lubrication is a preventative measure against epistaxis, the most common complication of NPA placement.
Insertion should be attempted first in the nostril that appears larger or less obstructed. Grasp the NPA at the flange and insert it gently with the beveled tip facing toward the nasal septum. This orientation allows the tube to follow the natural curve of the nasal floor and glide past the turbinates with less resistance and risk of injury. The tube should be advanced straight back, aiming toward the ear, not toward the top of the head.
If slight resistance is encountered, a gentle rotational movement of the NPA may help it pass over a turbinate or past minor anatomical variations. Forceful insertion is strictly avoided; if severe resistance or significant bleeding occurs, stop the procedure immediately. The device is properly seated when the flared flange rests against the patient’s nostril opening. The tube’s tip should then be positioned in the posterior pharynx, behind the tongue, maintaining the open airway.
Monitoring and Troubleshooting After Placement
Once the NPA is inserted, verify that it is functioning correctly to ensure proper air exchange. Check for signs of adequate ventilation, such as observing bilateral chest rise and feeling or hearing air movement through the tube’s opening. Continuous pulse oximetry monitoring should be established to track oxygen saturation levels. The patency of the NPA must be checked periodically, often by observing for condensation near the opening or by attempting to pass a suction catheter through it.
Several issues can arise after placement, requiring prompt troubleshooting. If the patient begins to gag or vomit, the NPA may be too long and stimulating the pharynx, necessitating immediate removal and re-insertion of a smaller size. If the NPA becomes obstructed by secretions, use an appropriate suction catheter to clear the lumen. Failure to easily pass a suction catheter suggests a blockage or kink, and a new NPA should be inserted in the opposite nostril if the initial placement is unsuccessful.
The NPA is a temporary measure and should be removed once the patient is conscious and can maintain their own airway without assistance. To safely remove the device, assess the patient’s ability to tolerate the procedure, and withdraw it gently. Following removal, the patient’s vital signs and respiratory status must be closely monitored to ensure the airway remains patent. Check the integrity of the skin around the nostril, especially if the NPA was in place for a prolonged period, to assess for pressure injury.