Nasopharyngeal Airway.pptx

A nasopharyngeal airway, also known as an NPA, nasal trumpet (because of its flared end), or nose hose, is a type of airway adjunct, a tube that is designed to be inserted into the nasal passageway to secure an open airway

1. Nasopharyngeal Airway Krishnakumar D AVMC&H

2. Introduction: A nasopharyngeal airway device (NPA) is a hollow plastic or soft rubber tubes that a healthcare provider can utilize to assist with patient oxygenation and ventilation in patients who are difficult to oxygenate or ventilate via bag mask ventilation, for example. NPAs are passed into the nose and through to the posterior pharynx. NPAs do not cause patients to gag and are, therefore, the best airway adjunct in an awake patient and a better choice in a semiconscious patient that may not tolerate an oropharyngeal airway due to the gag reflex.

3. Basic airway management in both the pediatric and adult populations includes assessing and managing airway patency, oxygen delivery, and ventilation. While NPAs are airway adjuncts for ventilation and oxygenation in patients who are difficult to ventilate and oxygenate . they only act as a bridge to either a secure airway via endotracheal or nasotracheal (NT) intubation or to assist the patient until the patient is stable and able to breathe independently. This activity describes the indications and contraindications for nasopharyngeal airways and highlights the role of the interprofessional team in the management of patients requiring them. All efforts should be taken to maintain a patient’s airway via non-invasive methodology unless indications for invasive airway management are apparent.

4. Indications: NPA uses conscious, semiconscious, or unconscious patient. NPAs are also helpful when a patient's mouth is difficult to open or access, for example, in cases of trismus or angioedema. OPA is not possible. Gag reflex, massive trauma around the mouth.

5. Contraindications: Absolute contraindications: NPA and NT intubation include signs of basilar skull fractures, facial trauma, and disruption of the midface, nasopharynx or roof of the mouth. Relative contraindications: Include suspected epiglottitis, coagulopathic patients (including those taking anti-coagulants) due to the risk of hemorrhage, large nasal polyps, and recent nasal surgery.

6. Equipment: 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; Magill forceps (if needed to remove easily accessible foreign bodies and patient has no gag reflex), to clear the pharynx as needed Nasogastric tube, to relieve gastric insufflation as needed There should be NT tubes in several sizes, lidocaine jelly or lubricant, topical vasoconstrictor (oxymetazoline 0.05%, phenylephrine 0.5%, cocaine), aerosolized 2% to 4% lidocaine, NPAs, syringe to inflate cuff, suction tubing, suction yanker, BVM, nasal cannula for apneic oxygenation if sedating, backup airway devices (LMA, glideslope, bougie, surgical airway, among others).

7. Preparation: Preparation for insertion of an NPA involves 2 steps. First, the healthcare provider obtains the correct size NPA, and second, the provider coats the NPA with lubricant, anesthetic jelly, or any water-soluble lubricant. In the ideal setting preparation for NT intubation can include all of the below-mentioned steps, but if the procedure is needed to be done emergently, the healthcare provider may be unable to prepare anything and may have to blindly insert the NT tube when that is the indicated route of securing the airway.

8. Preparatory steps, not necessarily in the below order, include: Positioning the patient in the sniffing position, attaching the patient to the monitor, pulse oximetry, blood pressure monitor and cardiac monitor. If available, set up end-tidal carbon dioxide monitor (capnography) Placing 2 peripheral intravenous (IV) accesses and starting 1 liter of crystalloid fluid (if the patient is not fluid overloaded or at risk of overload) Preoxygenation via nasal cannula, non-rebreather, BVM, BIPAP, in order to increase the oxygen reserve and the time to desaturation after a sedative and/or paralytic medication has been given. Having a BVM ready bedside Turning on wall suction, setting up the suction tubing and a yanker Having a respiratory therapist or other personnel prepared with a ventilator

9. Preparing sedative and paralytic medications if plan on sedating and/or paralyzing Having a CO2 detector, EtCO2 Setting up the backup airway Setting aside 6 to 7.5 cm NT tubes and checking the cuff of the tubes for an air leak If using flexible bronchoscopy, having the bronchoscope turned on and placed at bedside Placing the NT tube in warm sterile saline to allow the tube to soften and allow for a smoother insertion; this can decrease the risk for trauma to the nasal passageways.

10. Assessing for the more patent nostril, which can be done by asking the patient to hold one nostril and take in a deep breath, identifying which naris allows for more air movement. It can also be assessed by placing an NPA and judging which naris allows for easier insertion. If the provider will be utilizing a flexible bronchoscopy, then the scope can be used to visualize which nostril is more patent. Lubricating the tube and bronchoscope with lubricant or lidocaine jelly/ointment. Care should be used to avoid smudging the camera of the bronchoscope. Spraying a topical vasoconstrictor in bilateral nares to reduce bleeding risk Placing an NPA coated with lidocaine jelly/ointment to provide anesthesia and lubrication Spraying aerosolized lidocaine in the oropharynx Performing serial dilations of the bilateral nares or more patent nares with increasing larger diameter NPAs coated with lidocaine or lubricant

11. Technique: As necessary, clear the oropharynx of obstructing secretions, vomitus, or foreign material. Determine the appropriate size of the airway. When held against the side of the face, a correctly sized airway will extend from the tip of the nose to the tragus of the ear. Measure the length of the airway to ensure it does not cause obstruction. 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. .

12. Insert the airway posteriorly (not cephalad) 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. Advance the airway straight back until the flange is resting at the nostril opening

13. Complications: Complications with nasotracheal intubation include epistaxis, turbinate fracture, intracranial placement through a basilar skull fracture, and retropharyngeal dissection or laceration. Epistaxis, After successful nasotracheal intubation, patients may develop sinusitis, which can lead to sepsis. Blind placement increases the risk for oesophageal placement and retropharyngeal laceration, but otherwise, blind and bronchoscopic placement have similar complications.