I would surely rank the nasopharyngeal airway (NPA) as one of the most under-rated / under-utilized pieces of equipment in the EMT bag of tricks. They’re useful, simple and versatile. As a group, we tend to do a pretty good job oxygenating our patients, but I think we drop the ball on BLS airway adjuncts.

Most of our unresponsive or semi-responsive patients should be arriving at the ER with an NPA in place. If you’re bagging a patient they should have one … maybe two NPAs in place.

They’re fast, they’re friendly, they work much better on the semi-conscious and they don’t stimulate the gag reflex quite like their cousin the oropharyngeal airway. They also stay in place better, leaving the mouth open for examination and advanced airway techniques.

I’ve often had EMTs explain that they didn’t drop a basic airway adjunct because they knew I was right around the corner and I’d be intubating. That’s a poor excuse. When I arrive on scene I’d like to see that the EMT at the head has managed the BLS airway aggressively.

So let’s bone up on our NPA skills. Once you’re comfortable with these little beauties, they only take a few seconds to drop. You don’t need to make it a big production. Grab the right size, squirt a clump of KY on the end and go.

So let’s break it down and make you an NPA, quick draw, master.

1. Know where they are kept

That goes for the kit and the ambulance. I know this sounds painfully obvious and hopefully it is. If you can visualize exactly where the NPAs are in your kit and your cabinet right now you’re golden. But let’s face it … that’s not always the case.

Sometimes I ask for an NPA and my partner needs to fumble and unzip and peek here and there. “They aren’t in the airway roll brau. They’re on the side of the airway pouch on the … no … in the big kit … on the … Just give it here.”

Know where all the airway stuff is kept. Airway and AED are two items that you want to be able to access without looking. Those are your quick draw items. A gunfighter doesn’t need to look down to see which hip he’s wearing his gun on. Neither should you.

2. Grab the right size

Your EMT textbook might have explained that the proper way to measure is from the tip of the nose to the ear lobe. True. But you can grab the right size on the first try most of the time with this rule;

Big adults – grab the 8-9mm (24-27 french). Regular sized adults get a 7-8mm (21-24 french). Small adults get a 6-7mm (18-21 french). Kids start at 5mm and work down. When deciding if a patient is “big” or “regular” use their height as a guide, not their weight. Patient height is the most accurate predictor of correct NPA sizing.

This rule goes for all airway devices including OPA’s, Combi-tubes and King tubes.

I’d like to see the French go away. (The scale not the people.) (No … seriously, I’m a huge fan of the Tour De France) The French Scale System is even more complicated than the American measuring system and that’s not an easy feat. The metric measurements are just easier. But if your NPAs are in the French scale … you’ll need to learn it.

We tend to undersized our airway adjuncts. I’m not sure why. I think it starts in EMT school when we learn that the smaller NPAs go in the mannequin head easier. When faced with a real live nare we tend to opt for the smallest reasonable size.

Don’t do it. You’ll end up obstructing more usable nasal passage space than you create. Grab the correct size based on the sizing recommendations above.

3. Lube is your friend, but time is not

That little package of lubricant does help these things go in faster and it reduces damage to the nasal mucosa but don’t waste too much time coating the NPA with a shinny sheen of lube. Tear open the packet, squirt a clump of lube on the lower half of the NPA and get on with it.

The NPA doesn’t need a full, even, double coat of lubrication Bob Vila, and it doesn’t need a Swedsh massage either. It needs to get sunk it the nasal passage and you need to get on with managing the airway.

4. Don’t worry to much about the bevel

In EMT class they probably made a big deal about placing the bevel toward the septum. That is the preferred insertion technique, but nobody has ever really been able to convincingly explain to me why that is. Note that most NPAs are designed to be inserted in the right nostril. (If you follow the bevel rule.) But we also tell you to pick the largest nare.

So which takes precedence? Should we never use the left nare regardless of how tiny the right one might look? Or perhaps insert the NPA backwards? Do neither. Insert it in the largest nare with the curve of the NPA oriented toward the mouth and forget about the bevel.

5. Back and forth, back and forth, they DOWN

Some folks wiggle that thing back and forth like they’re trying to start a fire or something. Take it easy boy scout. Yes we taught you to use a gentle back and forth motion on the NPA as you insert it, but you don’t need to over-do it. Once you reach the mid-point of the NPA you should be able to just sink it. And your patient will thank you for it later.

The wiggling may facilitate the advance of the device but it isn’t terribly comfortable on the patients nose. And speaking of down. For the record these things aren’t going up the patient’s nose. They go strait back in to the nasal cavity and turn downward toward the posterior pharynx.

And there you have it. 10 seconds to help secure the airway and then move on.

It’s worth noting that there are some potential complications to NPA use. They are more likely after prolonged use and include:

  • Mucosal irritation
  • Sinusitis
  • Retropharyngeal ulcers
  • Temporary vocal cord paralysis
  • Temporary deafness

There have been two documented case of the NPA being inserted into the cranial vault after massive maxilo-facial trauma. The NPA should be avoided in patients with significant head and face trauma. Minor facial trauma is not a contraindication to NPA use.

Don’t let that list of complications go and scare you off. The NPA is a safe and useful tool. It stays in the airway bag far too often when the patient could benefit from its use. But not anymore … right? Right.

Now it’s your turn: Do you agree that the NPA is under-utilized? What has your experience been with the device. What advice would you give care givers who are unfamiliar with it? Leave a comment and let everyone know your take on the topic.