The Nasopharyngeal Airway (NPA), often called a nasal trumpet, is a flexible, soft tube inserted through the nostril into the posterior pharynx to maintain an open airway. This device helps secure a patient’s breathing pathway, especially when the tongue or relaxed soft tissues cause an obstruction. A primary advantage of the NPA is its tolerability in patients who are semi-conscious or have a reduced level of consciousness but still possess an intact gag reflex. Unlike an Oropharyngeal Airway (OPA), which can trigger a strong gag reflex, the NPA bypasses the sensitive oral area. It displaces the tongue and soft palate, ensuring a continuous channel for airflow to the trachea. This article is for informational purposes only and is not a replacement for formal medical training.
Patient Assessment and Sizing
A Nasopharyngeal Airway is indicated for patients who need airway support but cannot tolerate an OPA, such as those with an intact gag reflex, trismus (jaw muscle spasm), or significant oral trauma. The NPA provides a stable channel for air and can facilitate suctioning in individuals with excessive secretions or a weak cough.
The most significant absolute contraindications include severe facial trauma, especially in the mid-face region, or any suspicion of a basilar skull fracture. Signs like “raccoon eyes,” Battle’s sign (bruising behind the ear), or clear fluid leaking from the nose or ear may suggest a skull fracture. NPA placement is highly dangerous in these cases due to the risk of intracranial insertion.
Accurate sizing is essential. The length of the device is estimated by measuring the distance from the tip of the patient’s nose to the tragus of the ear (the small cartilage projection in front of the ear canal) or the angle of the jaw. This measurement ensures the tip of the airway rests optimally in the posterior pharynx, ideally about one centimeter above the epiglottis.
The diameter of the airway, measured in French units, must also be carefully selected to avoid trauma or obstruction. A general guide suggests choosing a diameter that approximates the size of the patient’s smallest nostril. For average-sized adults, common diameters range from 28 to 32 French.
Detailed Insertion Procedure
Select the nostril that appears larger or clearer and liberally coat the outside of the NPA tube with a water-soluble lubricant. Adequate lubrication minimizes friction and prevents injury to the delicate nasal mucosa, which can lead to a nosebleed.
The NPA should be inserted with the bevel—the slanted opening at the tip—facing toward the nasal septum (the wall separating the nostrils). This orientation helps the tube follow the natural curvature of the nasal passage. Advance the tube gently, directing the path horizontally and straight back toward the back of the head, essentially along the floor of the nose.
Avoid directing the tube upwards toward the eye, which can damage the delicate structures of the nasal turbinates. If resistance is met, a slight rotational or twisting motion may help navigate, but the airway must never be forced. Forcing the tube can cause significant trauma, including fracture of the turbinates or severe hemorrhage.
Once fully inserted, the flared end of the NPA, known as the flange, should rest flush against the opening of the nostril. Correct placement is confirmed by observing unimpeded airflow through the device, which may be heard or felt. If the patient is being ventilated with a bag-valve-mask, successful placement is indicated by visible chest rise and fall.
Troubleshooting and Post-Insertion Monitoring
The most frequent complication is epistaxis, or a nosebleed, due to mucosal injury during insertion. To manage this, the NPA should generally be left in place, as its pressure may help tamponade the bleeding. Removal is only necessary if the bleeding is severe or obstructs the airway.
If the patient begins to gag, cough, or vomit upon insertion, the tube is likely too long and stimulating the pharynx. The NPA should be immediately removed to prevent aspiration, and a shorter size attempted if needed. Obstruction is another potential complication if the tube kinks or becomes clogged with secretions.
After successful placement, continuous reassessment of the patient’s breathing and level of consciousness is necessary. Monitor the NPA position to ensure the flange remains seated against the nostril. Long-term monitoring is important, as prolonged use of an overly rigid or large tube can lead to pressure ulcers in the nasal or pharyngeal tissues.