An oropharyngeal airway (OPA) is a curved, rigid plastic device used as a temporary measure to maintain a clear upper airway in an unconscious patient. The device works by preventing the most common cause of airway obstruction in unresponsive individuals: the tongue. When deep unconsciousness occurs, the muscles of the jaw and tongue relax, allowing the base of the tongue to fall back against the posterior wall of the pharynx, blocking airflow. The OPA is an airway adjunct designed to hold the tongue forward, creating an open channel for breathing and facilitating ventilation during emergency care.
Indications and Safety Precautions
The decision to insert an OPA rests entirely on the patient’s level of consciousness and the presence of protective reflexes. Oropharyngeal airways are indicated for patients who are deeply unresponsive and whose airway obstruction is caused by the relaxation of the tongue and soft tissues. This intervention is often used during cardiopulmonary resuscitation (CPR) or when assisting ventilation with a bag-valve-mask device before advanced airway procedures can be established.
A safety check before placing an OPA is confirming the absence of a gag reflex. The gag reflex is a protective mechanism that prevents foreign objects from entering the throat. Its presence indicates that the patient is not sufficiently unconscious to tolerate the device. Stimulating an intact gag reflex with the OPA can trigger vomiting, which increases the risk of aspiration—the inhalation of stomach contents into the lungs.
If the patient is conscious, semi-conscious, or attempts to cough or swallow, an OPA should not be used. This stimulation can cause the vocal cords to spasm, a condition called laryngospasm, which completely blocks airflow. While the OPA prevents tongue obstruction, it does not create a seal or offer protection against the aspiration of fluid or stomach contents. The device is considered a temporary measure, and the patient must be monitored continuously for any signs of regaining consciousness or reflex activity.
Proper Sizing Assessment
Selecting the correct size of the OPA is important, as an improperly sized device can worsen the airway obstruction or cause tissue damage. The standard technique for sizing involves placing the OPA against the patient’s cheek. The flange, or flat end, should align with the patient’s lips or front teeth. The curved tip of the device should then extend to the angle of the jaw, or the earlobe.
A device that is too short will fail to adequately lift the tongue, potentially pushing the obstruction further into the pharynx. Conversely, an OPA that is too long risks extending past the base of the tongue and pressing down on the epiglottis. This pressure can force the epiglottis to close over the opening of the larynx, which obstructs the airway and can cause trauma to the surrounding structures.
Using the mouth-to-mandible measurement provides an initial approximation, but the final confirmation of appropriate sizing is clinical. The device must be inserted and the patient’s ventilation assessed for effectiveness. If the device does not relieve the obstruction, or if the patient’s breathing status does not improve immediately after placement, a different size must be selected. The OPA must be approximately 1 to 2 centimeters longer than the measured distance to account for the flange resting outside the mouth.
Detailed Insertion Technique
Preparation for OPA insertion begins with ensuring the patient’s mouth and pharynx are clear of any visible foreign bodies, secretions, or vomit, which may require suctioning. Once the appropriately sized OPA is selected, the insertion technique must be chosen based on the patient’s age to minimize the risk of trauma or pushing the tongue backward. The most common method for adult patients is the 180-degree rotation technique.
The airway is first inserted into the mouth with the curved tip pointing toward the roof of the patient’s mouth (cephalad). This initial orientation prevents the tip of the OPA from forcing the tongue backward into the pharynx as it is advanced. The device is then gently advanced about halfway into the oral cavity until the tip reaches the soft palate.
As the OPA passes the base of the tongue, it is rotated 180 degrees so that the curve points downward toward the back of the throat (caudally). This rotation maneuver allows the curved body of the device to slide over the tongue, seating the tip correctly in the posterior pharynx. The OPA is fully seated when the flange rests flat against the patient’s lips and the breathing channel is clearly open.
Pediatric Insertion
For infants and children, the 180-degree rotation method is generally avoided due to the higher risk of causing soft tissue trauma to the palate. Instead, the tongue depressor technique is preferred. A tongue blade is used to gently press the tongue down and forward. The OPA is then inserted directly with the curve already pointing downward, following the natural curvature of the tongue until the flange rests at the lips. Regardless of the method used, the procedure must be executed with gentle control to avoid injury to the gums, teeth, or soft palate.
Post-Insertion Monitoring and Removal
Once the OPA is successfully placed, the focus shifts to confirming that the intervention has been effective in establishing a patent airway. The patient’s chest must be observed for symmetrical rise and fall, and breath sounds should be auscultated to verify air is moving freely into both lungs. Skin color and pulse oximetry readings should be monitored for signs of improved oxygenation.
The patient must be continuously observed for signs of intolerance or the return of consciousness, which is the primary indicator for removal. If the patient begins to gag, cough, or actively tries to push the device out with their tongue, the gag reflex has returned. A stimulated gag reflex could lead to vomiting and aspiration, so the device must be removed without delay.
To remove the OPA safely, the mouth should be opened. The device should be gently pulled out, following the curve of the tongue to avoid causing further stimulation or trauma. Because the OPA is a temporary airway adjunct, the patient’s condition and level of consciousness must be frequently reassessed. If the patient’s airway becomes obstructed again after removal, a different airway management strategy must be implemented.