How To Insert a Nasopharyngeal Airway

• Sonorous respirations caused by upper airway obstruction in patients who are spontaneously breathing and have an intact gag reflex

• Sometimes for dilation and anesthesia of the nasal passage to prepare for nasotracheal intubation

Nasopharyngeal airways are better tolerated and are preferred for patients who are obtunded with intact gag reflexes. rather than oropharyngeal airways.

Nasopharyngeal airways can be used in some settings where oropharyngeal airways cannot, eg, oral trauma or trismus (restriction of mouth opening including spasm of muscles of mastication).

Nasopharyngeal airways may also help facilitate bag-valve-mask (BVM) ventilation.

Absolute contraindications:

• Suspected cribriform plate (basilar skull) fracture

Passage of the nasopharyngeal airway into the cranial vault through a disrupted cribriform plate has been reported but is rare (1).

Relative contraindications:

• Significant nasal trauma

Complications include:

• Epistaxis

• Gagging and the potential for vomiting and aspiration in conscious patients

• Sinusitis 

• Gloves, mask, and gown

• Towels, sheets, or commercial devices as needed for placing neck and head into sniffing position

• Various sizes of nasopharyngeal airways

• Water-soluble lubricant or anesthetic jelly

• Suctioning apparatus and Yankauer catheter to suction oral secretion or any liquids in the oropharynx

• Magill forceps (if needed to remove easily accessible foreign bodies in the oropharynx)

• Nasogastric tube, to relieve gastric insufflation as needed

• Two airways, one in each nostril, may be used to improve oxygenation and ventilation.

• An oropharyngeal airway may be used concurrently with nasopharyngeal airways if the patient does not have a gag reflex.

• Nasopharyngeal airways can usually be used even with major facial injuries, but care should be exercised to assure proper placement.

• Topical vasoconstrictors and/or anesthetics are sometimes used.

• Aligning the external auditory canal with the sternal notch may help open the upper airway and establishes the best position to view the airway if endotracheal intubation becomes necessary.

• The degree of head elevation that best aligns the ear and sternal notch varies (eg, no elevation in children with a large occiput, a large degree in patients with obesity).

The sniffing position—only in the absence of cervical spine injury:

• Position the patient supine on the stretcher.

• Align the upper airway for optimal air passage by placing the patient into a proper sniffing position. Proper sniffing position aligns the external auditory canal with the sternal notch. To achieve the sniffing position, folded towels or other materials may need to be placed under the head, neck, or shoulders, so that the neck is flexed on the body and the head is extended on the neck. In patients with obesity, many folded towels or a commercial ramp device may be needed to sufficiently elevate the shoulders and neck. In children, padding is usually needed behind the shoulders to accommodate the enlarged occiput.

Head and Neck Positioning to Open the Airway: Sniffing Position

A: The head is flat on the stretcher; the airway is constricted. B: The ear and sternal notch are aligned, with the face parallel to the ceiling (in the sniffing position), opening the airway. Adapted from Levitan RM, Kinkle WC: The Airway Cam Pocket Guide to Intubation, ed. 2. Wayne (PA), Airway Cam Technologies, 2007.

If cervical spine injury is a possibility:

• Position the patient supine or at a slight incline on the stretcher.

• Avoid moving the neck and perform the jaw-thrust maneuver. Do not perform the head tilt–chin lift.

• As necessary, clear the oropharynx of obstructing secretions, vomitus, or foreign material (using suction or Magill forceps).

• Estimate the appropriate length of the airway to be inserted. One method of estimation is to hold the airway against the side of the patient's face. The airway should extend from the tip of the nose to the tragus of the ear. (After insertion, assessment of ventilations should be made to determine if an airway of a different size should be substituted.)

• Open the nares to reveal the nasal passage. Inspect both nares to determine which side is wider.

• Lubricate the nasopharyngeal airway with water-soluble lubricant or anesthetic jelly such as lidocaine gel. Lubricate the nasopharyngeal airway with water-soluble lubricant or anesthetic jelly such as lidocaine gel.

• Insert the airway into the larger nasal passage, aiming posteriorly (not cephalad) and parallel to the floor of the nasal cavity, with the bevel of the tip facing toward the nasal septum (ie, with the pointed end lateral and the open end of the airway facing the septum). Use gentle yet firm pressure to pass the airway through the nasal cavity under the inferior turbinate.

• If you encounter resistance, try rotating the airway slightly and re-advance. If the tube still will not pass, try inserting it into the other nostril. Do not use excessive force.

• Advance the airway straight back until the flange is resting at the nostril opening.

• In patients who are breathing on their own, successful placement of the airway should result in normal breath sounds (eg, no longer with sonorous respirations).

• In patients requiring bag-valve-mask ventilations, when the airway is placed successfully, there should be minimal air leakage between the mask and the patient's face when the bag is squeezed.

How To Insert a Nasopharyngeal...

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• Ventilate the patient as appropriate. Use a head tilt–chin lift or jaw-thrust maneuver as necessary to lift the tongue and prevent it from obstructing the nasopharyngeal airway.

• Monitor the patient and identify and remediate any impediments to proper ventilation and oxygenation.

Minimize the risk of nasal bleeding by making sure the pointed end of the bevel is not scraping along the nasal septum; the opening should be toward the septum and the pointed end should be lateral.

1. 1. Martin JE, Mehta R, Aarabi B, Ecklund JE, Martin AH, Ling GS. Intracranial insertion of a nasopharyngeal airway in a patient with craniofacial trauma. Mil Med 2004;169(6):496-497. doi:10.7205/milmed.169.6.496