“A patent airway without opening the mouth.”

The Essentials

Overview

The nasopharyngeal airway (NPA) is a soft, flexible airway adjunct inserted through the nostril to maintain upper airway patency by bypassing obstruction at the level of the tongue and soft palate. It is especially useful when the mouth cannot be opened, when an oropharyngeal airway is not tolerated, or when you need an adjunct in a patient who is not deeply unconscious.

Description

An NPA is typically made of soft rubber or flexible plastic and consists of:

• Flange: Rests at the naris and limits depth of insertion.
• Flexible tube: Traverses the nasal passage into the nasopharynx.
• Beveled distal tip: Helps guide insertion and reduce trauma.

NPAs come in multiple diameters and lengths (often manufacturer color-coding). Correct sizing and lubrication are key to safe, effective use.

Indications

Use an NPA when you need to improve airway patency and the patient may not tolerate an OPA, or oral access is limited.

Common indications:

• Upper airway obstruction from tongue/soft tissue collapse (snoring respirations, poor air entry with BMV)
• Facilitation of bag-mask ventilation (particularly when an OPA triggers gagging)
• Patients with intact or partially intact gag reflex who still need an adjunct
• Trismus, clenched jaw, or limited mouth opening
• Adjunct during suctioning/airway toileting when appropriate

Clinical goal: reduce upper airway resistance and improve effective ventilation/oxygen delivery.

Contraindications

Absolute (practical)

• Known or suspected basilar skull fracture or severe midface trauma (classic “don’t” scenario)
• CSF rhinorrhea or clear signs of anterior skull base injury

Relative

• Significant nasal trauma or suspected nasal bone/cribriform injury
• Severe coagulopathy/anticoagulation (higher epistaxis risk)
• Nasal obstruction (polyps, severe septal deviation), prior nasal surgery
• Active epistaxis

If facial trauma is present, decide deliberately. When concern for skull base injury is high, avoid NPA and use other airway strategies.

Sizing

You need the right diameter and length.

Diameter (French size)

• Choose a size that approximates the patient’s small finger or nostril diameter.
• Typical adult sizes often used: 7.0–8.0 mm internal diameter (varies by manufacturer), smaller for petite adults.

Length

• Measure from the tip of the nose to the tragus of the ear (or angle of mandible, depending on local teaching).
• Too short fails to bypass obstruction, too long can irritate the larynx and provoke coughing or laryngospasm.

When in doubt, prioritize adequate length to reach the nasopharynx while ensuring gentle insertion and patient tolerance.

Technique for Placement

Preparation

1. Position: Neutral or sniffing as appropriate. Use jaw thrust if needed.
2. Select nostril: Ask about prior fractures, obstruction, or “better side” if awake. Inspect quickly for patency if time allows.
3. Lubricate generously: Water-soluble lubricant reduces trauma and epistaxis risk.
4. Consider topical vasoconstrictor if available and clinically appropriate (institution-dependent), especially if bleeding risk is a concern.

Insertion

1. Hold the NPA with the bevel toward the septum (common approach to reduce turbinate trauma).
2. Insert into the nostril along the floor of the nose (straight back, not up).
3. Advance gently with steady pressure. If resistance is met:
   • Stop, withdraw slightly, adjust angle, rotate subtly, and re-advance.
   • If still resistant, try the other nostril or a smaller size.
4. Advance until the flange rests on the naris.

Avoid force. Force creates bleeding, swelling, and a worse airway.

Confirmation of Effect

• Improved ease of BMV, better chest rise
• Decreased obstructive sounds (less snoring/stridor from soft tissue collapse)
• Improved ventilation monitoring if available (capnography waveform during assisted ventilation)

Troubleshooting and Removal

• Epistaxis: remove if significant, apply pressure, suction, switch nostril/size, or use alternative adjunct.
• Coughing/gagging: may indicate the tube is too long, too large, or patient is too reactive. Remove and reassess.
• No improvement: suspect incorrect size, malposition, or a different primary problem (seal, severe obstruction below the pharynx, laryngospasm, bronchospasm).

Remove when no longer needed or if complications occur.

Complications (worth knowing)

• Epistaxis and nasal mucosal trauma
• Turbinate injury, rare ulceration with prolonged use
• Gagging/coughing, laryngospasm in reactive patients
• Misplacement (rare but catastrophic in high-risk facial trauma scenarios)
• Increased airway resistance if diameter is too small

If you want, I can also add a tight “NPA vs OPA” comparison box for your textbook chapter, including: who tolerates what, quick sizing rules, and failure patterns (bleeding, too short, too long, wrong angle).

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