Nasopharyngeal Airway (NPA) (2025)

Overview of Nasopharyngeal Airway

Basic airway management involves checking airflow, supplying oxygen, and controlling breathing in children and adults. The goal is to keep the air flowing naturally, without performing surgeries or other procedures unless they are necessary.

Several methods can be used to support the airway without any surgical intervention. These include:

Providing oxygen through a nasal tube or an oxygen mask
Helping someone breathe using a device called a Bag-Valve-Mask (BVM)
Using positive pressure ventilation which is a method of helping to breathe by increasing pressure in the airway. This can include using a BVM with a special valve, or devices called CPAP (Continuous Positive Airway Pressure) and BiPAP (Bilevel Positive Airway Pressure).
Using special airway devices like the King Tube and laryngeal mask which deliver oxygen directly to the windpipe

If these non-invasive methods are not enough to support the airway, more involved techniques might be needed. These procedures provide a secure airway and include placing the patient on a mechanical breathing machine. Some methods that doctors use in these cases are:

Endotracheal intubation, where a tube is inserted either through the nose or mouth directly into the windpipe to assist with breathing
Needle jet ventilation, where air is pumped directly into the lungs through a needle.
Cricothyroidotomy, a surgical procedure to create a hole in the neck to breathe through
Tracheostomy, a surgical procedure to create a direct airway through the neck and into the windpipe

Needle jet ventilation can be used in children younger than 8 years, while Cricothyroidotomy is appropriate for adults and those older than 8 years.

Choosing the right technique depends on the patient’s individual situation, such as their weight, the size of their tongue, whether they’ve suffered any injuries, if they’re wearing a neck brace, whether they have a gag reflex, and their age.

Once the best approach is determined, the patient’s head is positioned for maintaining an open airway. Here are the methods for positioning the patient’s head:

Head tilt-chin lift maneuver: One hand tilts the forehead while the other hand lifts the chin. This extends the neck, helps reduce any blockages and aligns the airways. In this position, the patient’s nose is pointed up and forwards.
Chin lift: Both hands are placed under the jaw and chin. The jaw is then lifted until the teeth barely touch.
Jaw-thrust maneuver: With the spine in a neutral position, the sides of the jaw are lifted forward to open the airway. This is the preferred method for individuals who may have a neck injury.

It’s important to realize that there are differences between managing the airways of children and adults. For example, pre-teen children have a large back of the head that can cause the neck to bend excessively and block the airway. The head tilt-chin lift maneuver can correct this problem. But, it should be used carefully in children with a weak windpipe because overextending the neck can also block the airway. In children with large or soft tongues that obstruct the airway, the jaw-thrust maneuver might be a better option.

Once the patient is positioned correctly, breaths can be given by mouth-to-mouth or via the BVM ventilation. If this doesn’t work, additional aids like oral pharyngeal airways (OPAs) or nasopharyngeal airways (NPAs) can be used to maintain an open airway. OPAs are suitable for patients who are unresponsive, while NPAs can be used on both conscious and unconscious patients. NPAs are therefore useful if breathing tubes aren’t needed right away or if the process needs to be delayed. They can also be temporarily used if conscious intubations are necessary.

NPAs are tubes inserted into the nose and throat that don’t cause gagging, making them ideal for awake patients. They can also be used for semi-conscious patients who have a working gag reflex and might not tolerate an OPA. NPAs might also come in handy when it’s hard to open a patient’s mouth. However, NPAs can only keep the airway open in stable patients who are breathing on their own. They serve as a temporary measure for patients who need an endotracheal (ET) or nasotracheal (NT) airway.

It’s worth mentioning that although NT intubation was traditionally popular among critical care and emergency physicians, most doctors today favor the ET intubation method, as it has demonstrated better outcomes and fewer complications. Oral and maxillofacial surgery are the only fields where NT intubation is extensively used. It has been found that using an NPA before an NT intubation during surgery can make tube insertion easier and reduce bleeding.

Anatomy and Physiology of Nasopharyngeal Airway

The nose has connections with several parts of the body, including the sinuses on your face, the brain, through a structure called the cribriform plate, the pharynx which is the part of the throat behind the mouth and nasal cavity, the esophagus, which is commonly known as the food pipe, and the trachea or the windpipe via the nasopharynx, which is the upper part of the pharynx that connects with the nasal cavities.

Why do People Need Nasopharyngeal Airway

Using the nose to open up a patient’s airway is often the first and sometimes the only option in emergency situations. Placing a breathing tube through the nose and into the windpipe is used to help patients who have:

Strong reflex to gag
Trouble opening their mouth
An enlarged tongue (macroglossia)
Instability in the bones of the neck (cervical spine)
Intense curving of the neck (severe cervical kyphosis)
Intense arthritis
Masses in their mouth
Structural abnormalities
Tightening of the jaw muscles (trismus)
Swelling caused by a collection of excess fluid (angioedema)

Moreover, this method of putting a breathing tube in via the nose should be thought about before any surgery involving the face or dental procedures. It is also better tolerated when the patient is awake. It should be used when a patient needs to be awake during the procedure of inserting the breathing tube.

This breathing tube is helpful in challenging situations where the patient has a difficult airway or continually low oxygen levels, even though they are getting oxygen. This is often the case with patients who have heart failure, long-term lung disease known as chronic obstructive pulmonary disease (COPD), or very bad asthma. These patients need to keep their lung function under their control while their airway is secured. Using drugs to make these patients sleep or paralyze them can make managing their airway even harder. Also, they may have trouble lying flat due to shortness of breath when they lie down (orthopnea). In these patients, the breathing tube can be put in while they are awake and sitting up.

This method is commonly used during mouth and face surgery. This type of airway lets doctors see the patient’s mouth well during the procedure. Just as noted earlier, inserting a nasal tube into the nostril can make the process of placing the nasal breathing tube easier and can reduce the chances of bleeding during the procedure.

When a Person Should Avoid Nasopharyngeal Airway

There are several conditions where placing a Nasopharyngeal Airway (NPA), a tube used to help patients breathe, might not be the best option. These include individuals who might have a condition that causes the throat to swell dangerously (epiglottitis), those who have large nasal polyps (growths in the nose), those who have recently had nose surgery, those who have issues with their blood clotting (coagulopathy), and those who are taking blood thinners (anticoagulants). One of the risks involved with these conditions is the nose bleeding excessively because of abnormal blood clotting.

However, there are more serious situations where inserting an NPA or a Nasotracheal Tube (a different type of breathing tube) are absolutely not advisable. These include individuals who have a fracture at the base of their skull, significant injuries to their face, or damage to the middle part of their face, the area in the back of their nasal cavity (nasopharynx), or the roof inside their mouth.

Equipment used for Nasopharyngeal Airway

When an NPA (Nasopharyngeal Airways) device is being placed, it’s crucial to have the right tools and equipment at hand. These include different sizes of NPA devices, Lidocaine jelly (a local anesthetic), a type of nasal spray used to constrict blood vessels in the nose (like oxymetazoline 0.05% or phenylephrine 0.5%), and lidocaine in aerosol form. You’ll also need a suction tube and a suction “yanker,” a BVM (Bag-Valve-Mask) for breathing assistance, and a nasal cannula for delivering oxygen if the patient is sedated. Additionally, it’s necessary to have alternative tools for managing the patient’s airway, such as a laryngeal mask airway, glideslope, bougie, and surgical airway tools.

The right size of the NPA device is vital to ensure the patient’s airway is kept open and to reduce potential complications. For adults, NPA sizes typically range from 6 to 9 cm. NPA sizes of 6 to 7 cm are usually adopted for adults with smaller builds, whereas a 7 to 8 cm NPA is suitable for medium-built adults. A larger-built adult may require an 8 to 9cm NPA. The “earlobe” or “tragus technique” can also be used to estimate the suitable NPA size.

In this method, one end of the NPA is positioned at the tip of the patient’s nose and the other end pointing toward the earlobe. If the NPA just reaches the earlobe, it’s the correct size.

Another way of estimating the NPA size in adults is the “mandible technique”, in this, the NPA is placed at the nasal opening and oriented toward the angle of the jaw. If the NPA is too long it will cross the jawline and if it is short it does not reach the jawline.

For pediatric patients, choosing the NPA size is less straight forward. NPA sizes can range from 3 for a preterm baby to 6 for a child between 9 to 12 years old. Typically, the NPA size is similar to an ET (Endotracheal) tube size or half a millimeter larger. In determining the size, the length is more significant than the internal diameter. Research suggests children’s height may be a better indicator of the correct NPA size. If different lengths of NPAs are available for a single diameter, then the longest one is preferred.

Broselow tape is another way to determine the NPA size for pediatric patients. This color-coded tape measures a child’s height to determine their proper equipment size. The tape can also guide the selection size for other resuscitation equipment and medications.

Who is needed to perform Nasopharyngeal Airway?

Stabilizing someone’s airway, which means keeping the airways open, is a skill that healthcare professionals are trained to do. These professionals understand how the head, neck, and lungs function. They are well-trained to place a device called a Nasopharyngeal Airway (NPA), which helps a patient breathe more easily.

This kind of procedure is usually carried out by medical professionals in different fields such as medicine, nursing, and respiratory therapy. Professionals who provide medical assistance before a patient reaches the hospital, known as prehospital providers, can also stabilize the airway under the supervision of a highly trained healthcare professional.

In some places, these prehospital providers are allowed to stabilize the airway on their own if they are trained to do so. Many emergency medical service personnel are well-trained to handle NPAs.

Inserting a Nasotracheal (NT) tube, another type of breathing assistance tool, doesn’t often happen in the emergency department. But if needed, emergency physicians who are not familiar with the procedure may ask an anesthesiologist (a doctor who specialize in pain-related medication and procedures) or an otolaryngologist (a doctor who specialize in ear, nose, and throat health) on duty to perform this procedure.

Nurses and respiratory therapists are well-equipped too to insert an NPA. They also have the necessary training to monitor a patient’s breathing and make sure that the airway device stays secured and that the oxygen supply is sufficient.

Preparing for Nasopharyngeal Airway

Preparing to insert a breathing tube through the nose, also known as a Nasopharyngeal Airway (NPA), generally involves two main steps. First, the doctor needs to get the right size NPA. The second step is to coat the tube with a special jelly that makes it slide in easier and can numb the area to reduce discomfort. However, in an emergency or when there aren’t enough resources, the person performing this procedure may not have time or the tools to prepare properly and they may have to put the tube in without being able to see clearly.

There are also other important steps that need to be done during the preparation, but not necessarily in this order:

1. Attaching devices that monitor the patient’s blood oxygen levels, blood pressure, and heart rate.
2. Positioning the patient so that they are in a “sniffing” position, which can make it easier to insert the NPA.
3. Setting up a device to monitor the carbon dioxide levels in the patient’s breath.
4. Inserting needles for intravenous access on both sides.
5. If the patient is not in danger of fluid overload, starting a liter of fluids through the intravenous line.
6. Providing the patient with oxygen through different methods to increase their oxygen levels before the procedure.
7. Making sure the oxygen mask fits tightly over the patient’s mouth and nose.
8. Having a special bag that can be used to help the patient breathe (BVM) ready at the bed.
9. Turning on the wall suction and preparing the tubing to remove any unwanted materials.
10. Getting the respiratory therapist to prepare a ventilator, a machine that can help with breathing.
11. Preparing any sedative or muscle relaxant medications that may be needed.
12. Having back-up breathing tubes of different sizes ready.
13. Checking the tube for any air leaks.
14. Using a special spray to tighten up the blood vessels in the patient’s nose to reduce the risk of bleeding.
15. Coating the NPA with a numbing jelly to reduce discomfort.
16. Properly placing the correct NPA.

Once the tube is in place and the airway is secure, it should be removed promptly to lessen any potential complications.

How is Nasopharyngeal Airway performed

The Nasopharyngeal Airway (NPA) is a tube that is inserted into the nose to help with breathing. It goes into the most open nostril and needs to face downwards to easily slide into the back of the nose. If there’s resistance when inserting the NPA, it can be gently rotated to fit more snugly. The tube needs to be directed towards the back, along the floor of your nose. This ensures it goes via the lower part of the nostril, preventing it from going upwards which could cause discomfort.

After the NPA is inserted, the doctor will check inside your mouth. If you see the tube sticking out below the uvula (the fleshy extension at the back of the soft palate which hangs above the throat), it means the tube is too large. Once the NPA is in place, the doctor may choose to put in a more secure airway tube, like an Endotracheal (ET) or Nasotracheal (NT) tube, if needed.

Possible Complications of Nasopharyngeal Airway

When a patient has a nasopharyngeal airway (NPA) placement or nasotracheal (NT) tube inserted, there could be possible complications. These might include:

Bleeding from nose injuries (Epistaxis)
A fracture of the small bone clusters in the nose (turbinate fracture)
Removal of the bone clusters in the nose (Turbinectomy)
Accidental placement of the NPA tube in the brain due to a serious skull fracture
Damaging the soft tissue at the back of the throat (Retropharyngeal laceration)
An infection in the sinuses (Sinusitis), which could lead to whole-body infection for those with weaker immune systems
Stomach swelling if the NPA is too big or the NT tube ends up in the foodpipe instead of the airpipe

If the NT tube is inserted without proper guidance like a bronchoscope, it increases the risk of it ending up in the food pipe (esophagus) and causing injury at the back of the throat. However, the overall likelihood of complications are similar with or without the use of a bronchoscope.

The NPA should never be placed if the patient has a severe skull fracture at the base of the skull (basilar skull fracture). This could risk the NPA being pushed upwards, causing harm to the brain.

Stomach swelling because of incorrectly placed airway tubes can lead to vomiting, which increases the risk of pneumonia caused by inhaling stomach contents into the lungs. This can then interfere with the oxygen supply and ventilation of the lungs, which is a critical factor for life support.

A blockage in the throat can occur if an NPA is left in place for longer than usual duration. Despite this, it is sometimes feasible to keep an NPA in place if there is good communication between medical service providers such as the emergency teams, intensive care units, and ear-nose-throat departments. An appropriately inserted NPA can stay in place for up to 20 months, though it might cause a reaction due to the body recognizing it as a foreign object.

Like any other medical procedures, these air management procedures also have some risks. However, operating on the right patients and applying suitable techniques can help prevent most of the unwanted complications.

What Else Should I Know About Nasopharyngeal Airway?

A Nasopharyngeal Airway device (NPA) is a useful tool that helps to keep someone’s airway open if they’re still able to breathe on their own and have a working gag reflex. This can come in handy for people who are experiencing heart or breathing problems, going through oral or facial surgery, or have a complex airway. The NPA also provides an open and clear path for Endotracheal or Nasotracheal tubes (ET or NT, these are tubes placed into the windpipe through the mouth or nose) if doctors need to establish a more secure airway.