9 Nasopharyngeal and Oral Airway Insertion 63

PROCEDURE Nasopharyngeal and Oral 9 Airway Insertion

Kimberly Wright PURPOSE: Nasopharyngeal and oral airways are used to provide short-term airway maintenance and to facilitate the removal of tracheobronchial secretions.

5 PREREQUISITE NURSING ❖ Patients with obstructed nasal passageways KNOWLEDGE ❖ Patients with suspected basilar skull or cribriform plate fracture5 Nasopharyngeal Airway ❖ Patients with facial trauma that prevents the safe inser- • Nasopharyngeal airways are inserted into a single naris tion or use of the airway 3,5 and passed into the posterior oropharynx to the base of the tongue ( Fig. 9-1 ).2 Oropharyngeal Airway • The nasopharyngeal airway has three parts: the fl ange, • Oropharyngeal airways are typically disposable, curved, cannula, and bevel or tip. The fl ange is the wide trumpet- plastic or hard rubber devices with an opening or channel like end that prevents further slippage into the airway. The to facilitate suctioning. 1 hollow shaft of the cannula permits airfl ow into the hypo- • The oropharyngeal airway is placed over the tongue. The pharynx. The bevel or tip is the opening at the distal end curvature or body of the airway displaces the tongue of the tube. When the correct size is properly inserted, the forward from the posterior pharyngeal wall, a common fl ange will rest against the patient’ s naris 3 and the tip can site of airway obstruction. be seen resting posterior to the base of the tongue. • An oropharyngeal airway has four parts: the fl ange, body, • The external diameter of the nasopharyngeal airway tip, and channel ( Fig. 9-3 ). The fl ange rests against the should be slightly smaller than the patient’ s external nares lips. This design protects against aspiration into the opening. The length of the nasopharyngeal airway is airway. The body of the airway curves over the tongue. determined by measuring the distance between the tip The tip is the distal-most part of the airway toward the of the patient’ s nose and the tip of the patient’ s earlobe base of the tongue. ( Fig. 9-2 ). 3 Improperly sized nasopharyngeal airways may • Oral airways are manufactured in a variety of sizes for result in increased airway resistance, limited airfl ow (if adults, children, and infants. Sizing depends on the age the airway is too small), kinking, mucosal trauma, gagging, and size of the patient (Table 9-1). An alternative method vomiting, and gastric distention (if the airway is too used to select the size of an oral airway is to place the large).5 oropharyngeal airway on the space between the patient’ s • The advantages of the nasopharyngeal airway include ear lobe and the corner of the patient ’ s mouth ( Fig. 9-4 ).3 ease and rapidity of insertion, increased comfort and toler- • Improperly sized airways can cause airway obstruction (if ance in a conscious patient, decreased incidence of gag they are too small) and tongue displacement against the refl ex stimulation, minimal incidence of mucosal trauma oropharynx (if they are too large).3 during frequent suctioning, and the ability to be inserted • Oropharyngeal airways are contraindicated in a conscious when the patient ’ s teeth are clenched.1,5 patient as they may stimulate a gag refl ex and further put • In selected patient situations, a nasopharyngeal airway the airway at risk for compromise due to vomiting. 2 may be used to facilitate the passage of a fi beroptic bron- • An oropharyngeal airway may be used in conjunction with choscope and to tamponade small bleeding blood vessels an oral endotracheal tube to facilitate artifi cial ventilation, in the nasal mucosa. acting as a bite-block and preventing damage to the endo- • Most available nasopharyngeal airways are designed to be tracheal tube, tongue, and soft tissues of the mouth. placed into the right naris. Therefore, when inserted in the • Oropharyngeal airway placement should never be left naris, the airway adjunct must be rotated until the attempted in a patient who is actively demonstrating bevel is facing the nasal septum.3 seizure activity. • Contraindications to the use of a nasopharyngeal airway are as follows: EQUIPMENT ❖ Patients undergoing anticoagulation or antiplatelet therapy5 • Appropriately sized nasal or oral airway ❖ Patients prone to epistaxis • Nonsterile gloves

62 9 Nasopharyngeal and Oral Airway Insertion 63

Flange Lips

Cannula Measure jaw angle Bevel A Flange Cannula

Figure 9-4 Alternative Method for Selecting the Size of an Oro- pharyngeal Airway. (From Eubanks DH, Bone RC: Comprehensive respiratory care: A learning system , St. Louis, 1990, Mosby, 552.) B Tip Figure 9-1 Nasopharyngeal Airway. A , Airway parts. B , Proper placement. (From Eubanks DH, Bone RC: Comprehensive respiratory care: A learning system , St. Louis, 1990, Mosby, 518.)

Measure to tragus of ear

Flange secured with safety pin and tape

Airway tip

B Figure 9-2 A, Estimating nasopharyngeal airway size. B , Nasopharyngeal position after insertion. (From Eubanks DH, Bone RC: Comprehensive respiratory care: A learning system , St. Louis, 1990, Mosby, 552.)

Flange Body Oropharyngeal tube in place

Tip A Channel Flange Body

Channel BCTip Figure 9-3 Oropharyngeal Airways. A , Guedel airway. B , Berman airway. C , Properly inserted oropharyngeal tube. (From Eubanks DH, Bone RC: Comprehensive respiratory care: A learning system , St. Louis, 1990, Mosby, 518.) 64 Unit I Pulmonary System

TABLE 9-1 Oral Airway Sizes airways are generally used for temporary airway maintenance.2 Diameter of Oral Size of Oral • Assess neurological status and assess for the presence of Size of Patient Airway (mm) Airway (Guedel) the gag refl ex. Rationale: Evaluation of the patient ’ s neurological status assists in determining the need for an Large adult 100 5 artifi cial airway. Presence or absence of the gag refl ex can Medium adult 90 4 help the nurse select the most appropriate airway adjunct. Small adult 80 3 • Assess cardiopulmonary status. Rationale: Evaluation of the patient’ s cardiopulmonary status assists in determining From Cummins RO, editor: Airway, airway adjuncts, oxygenation, and ventilation. In ACLS: principles and practice , Dallas, 2003, American Heart Association, 145. the need for an artifi cial airway. • For nasal insertion, assess the nasal passageway for any apparent obstruction or deformity.3 With fi nger pressure, occlude one nostril; feel for air movement under the open nostril. Patency also can be assessed with inspection of • Tongue depressor each naris with a fl ashlight. Rationale: Assessment of • Water-soluble lubricant (nasopharyngeal airway) patency promotes smooth, quick, unobstructed airway • Tape (nasopharyngeal airway) insertion, and reduces the risk for injury or bleeding. Additional equipment, to have available as needed, includes • For nasal insertion, consider contacting the practitioner the following: for an order to apply a topical anesthetic to coat the nasal • Goggles, glasses, or face mask passageway. Rationale: Topical anesthetics with a vaso- • Suction equipment constrictor help shrink nasal mucosa and decrease the incidence of trauma and bleeding. PATIENT AND FAMILY EDUCATION • For oral insertion, assess the condition of the oral mucosa, dentition, and gums. Rationale: Preprocedural assessment • Explain the purpose of the airway and the procedure to provides baseline information for later comparison. conscious patients or to the family of an unconscious • For oral insertion, remove loose-fi tting dentures and any patient, if the patient’ s condition and time allow. Ratio- foreign objects (including partial plates, tongue studs, lip nale: This process identifi es family knowledge defi cits rings) from the mouth. Rationale: Removal ensures that about the patient’ s condition, the procedure, its expected objects do not advance further into the airway during benefi ts, and its potential risks and allows time for ques- insertion. tions to clarify information and voice concerns. Commu- nication and explanation regarding therapy are cited as Patient Preparation important needs of patients and families to relieve anxiety • Verify correct patient with two identifi ers. Rationale: and encourage communication. Prior to performing a procedure, the nurse should ensure • Discuss the sensory experiences associated with airway the correct identifi cation of the patient for the intended insertion, including the presence of an airway in the nose intervention. (nasal), the inability to clench teeth together (oral), and • Select the appropriate size of the airway adjunct by mea- possible gagging. Rationale: Knowledge of anticipated suring as outlined previously in the Prerequisite Nursing sensory experiences reduces anxiety and distress. Knowledge section. Rationale: Airway adjuncts must be of the appropriate length and diameter to achieve airway patency. PATIENT ASSESSMENT AND • Position the patient. For nasal insertion, unless contrain- PREPARATION dicated, a supine or high Fowler’ s position is acceptable. For oral insertion, the supine position is preferred. Ratio- Patient Assessment nale: This positioning promotes patient and nurse comfort • Assess the patient ’ s need for long-term airway mainte- and provides easy access to the external nares or oral nance. Rationale: Nasopharyngeal and oropharyngeal cavity.

9 Nasopharyngeal and Oral Airway Insertion 65

Procedure for Nasopharyngeal Airway Insertion Steps Rationale Special Considerations 1 . HH 2 . PE To reduce the risk of exposure to exhaled or coughed secretions, consider donning protective eyewear and face mask. 3. Assess the airway for the need to Facilitates visualization of nasal Suction should always be available to suction blood or secretions. structures and potential obstacles clear the airway of any visible to insertion. secretions or foreign bodies.6 (Level D * ) 4. Generously lubricate the tip Facilitates passage of the device and outer cannula of the airway into the correct position while with water-soluble lubricant. 2–4 reducing friction-related trauma. (Level D) 5. Elevate the tip of the nose and Following the natural contour of If resistance is encountered, rotate the gently slide airway into nostril. the nasal passage decreases the tube and continue gentle forward Guide it posteriorly and toward incidence of trauma. pressure. Do not force the tube. If the ear, along the nasal passage resistance continues, withdraw the until the fl ange rests against the tube and try the other nostril. nostril.2 (Level D) During tube insertion, if the patient has increasing dyspnea or respiratory distress, consider removing the tube. 6. Visualize the oropharynx and tip Verifying the location of the airway of the nasopharyngeal airway to in the pharynx confi rms proper ensure effective positioning has airway positioning and allows for been achieved (see Fig. 9-2). inspection of posterior pharynx for excessive bleeding or mucus. 7. Reassess airway patency.3 Feel Optimal airway positioning allows for air movement over the fl ange. for forward airfl ow, removal of Listen for snoring or other secretions, and possible sounds concerning for upper prevention of airway occlusion. airway obstruction. (Level D) 8. Suction secretions as needed. Maintains patent airway. Recheck fl ange for proper position. 9. Consider the need for bag-mask If respiratory effort is insuffi cient Nasopharyngeal airways are intended ventilation or the need for or copious secretions threaten for short-term use to temporarily placement of a defi nitive airway.3 airway patency, additional facilitate ventilation. (Level D) measures are required to maintain adequate ventilation. 10. Follow institution standard for Identifi es need for pain Continued pain despite pain assessing pain. Administer interventions. interventions. analgesia as prescribed. 11. Discard used supplies and equipment. 12. Remove gloves and perform hand hygiene

* Level D: Peer-reviewed professional and organizational standards with the support of clinical study recommen dations.

Procedure continues on following page 66 Unit I Pulmonary System

Procedure for Oropharyngeal Airway Insertion Steps Rationale Special Considerations 1 . HH 2 . PE Protective eyewear or face masks should be worn in the presence of copious secretions. 3. Suction the mouth and pharynx Clears airway of secretions, blood, with a rigid pharyngeal suction tip and vomit so that they do not (Yankauer) catheter, if blood or enter the airway with airway secretions are present. insertion. 6 ( Level D*) 4. Open the patient ’ s mouth with the Provides access to oral cavity. chin-lift maneuver crossed-ﬁ nger technique ( Fig. 9-5 ).3 (Level D)

Figure 9-5 Crossed-Finger Technique for Opening the Mouth. (From Eubanks DH, Bone RC: Comprehensive respiratory care: A learning system , St. Louis, 1990, Mosby, 631.)

5. Remove poorly fi tted or broken Poorly fi tted or broken dentures can Consider leaving well-fi tted dentures dentures, if present. hinder the insertion of the airway in place to maintain structure and adjunct and can pose additional support for the oropharyngeal risk for airway obstruction. airway. 6. Insert oral airway with curved end Prevents posterior tongue Remove the airway immediately if the up ( Fig. 9-6A ), or lateral to displacement. patient gags, gasps for air, or begins tongue. 4 A tongue depressor may breathing irregularly. The airway assist in tongue control during should never be inserted end-up in insertion. (Level D) children, as this poses increased risk for damage to the soft palate.

Airway tip points up Figure 9-6 Insertion of an Oro- pharyngeal Airway. A , Advance airway with curved end up. Airway rotated B , Rotate airway 180 degrees. 180 degrees (From Eubanks DH, Bone RC: Comprehensive respiratory care: A learning system, St. Louis, 1990, Mosby, 551.)

A B

*Level D: Peer-reviewed professional and organizational standards with the support of clinical study recommendations. 9 Nasopharyngeal and Oral Airway Insertion 67

Procedure for Oropharyngeal Airway Insertion—Continued Steps Rationale Special Considerations 7. Advance oral airway over the base Prevents posterior tongue of the tongue until the fl ange is displacement. parallel with the patient ’ s nose. 8. Gently rotate the tip to point down Positions the airway adjunct to hold When the oral airway is properly (see Fig. 9-6B ); the fl ange should the tongue in the normal sized, the fl ange should rest against rest against the patient ’ s lips. anatomical position.3 (Level D*) the patient ’ s lips (see Fig. 9-4 ). 9. Verify airway patency by Proper placement and size are ventilating the patient with a essential for securing and bag-mask device and carefully maintaining a patent airway.2,3 assessing for resistance or (Level D) obstruction. 10. Suction pharynx as needed. Maintains patent airway; pooled secretions provide a medium for bacterial growth. 11. Reassess the patient ’ s respiratory Validates the effectiveness of the status. oral airway. 12. Consider the need for placement If respiratory effort is insuffi cient Oropharyngeal airways are intended of a defi nitive airway.3 (Level D) or copious secretions threaten for short-term use to temporarily airway patency, additional facilitate ventilation in the measures are required to unconscious patient. 3 maintain adequate ventilation. 13. Discard used supplies and equipment. 14. Remove PE and perform hand hygiene.

*Level D: Peer-reviewed professional and organizational standards with the support of clinical study recommendations.

Expected Outcomes Unexpected Outcomes • Airway patency maintained • Pulmonary aspiration • Effective removal of tracheobronchial secretions • Inability to insert airway due to patient condition • Effective positioning of airway and displacement of • Airway obstruction tongue away from hypopharynx • Nasal or oral mucosal trauma or ulceration • Epistaxis

Patient Monitoring and Care Steps Rationale Reportable Conditions These conditions should be reported if they persist despite nursing interventions. 1. In the rare event the adjunct must Allows for more complete • Redness remain in place for a prolonged inspection of the mucosa, • Swelling period of time, assess skin and cavity, and surrounding tissues; • Drainage mucosa in contact with airway enables complete hygiene. • Bleeding adjunct every 8–12 hours. • Skin breakdown 2. Consider removing and reinserting a new nasal airway in the opposite naris each assessment to prevent skin breakdown. Procedure continues on following page 68 Unit I Pulmonary System

Patient Monitoring and Care —Continued Steps Rationale Reportable Conditions 3. Provide meticulous oral care Decreases secretions, • Lacerations every 2–4 hours and as needed. encrustations, oral infections, • Ulcerations and airway port occlusions. • Areas of necrosis • Drainage 4. Oxygenate and suction as Retained secretions increase the • Change in character or amount necessary, per assessment. potential for airway obstruction of secretions and pulmonary infections. 5. Monitor respiratory status every Change in respiratory status may • Change in respiratory status not 2–4 hours. indicate displacement of corrected with repositioning of airway or worsening airway or suctioning respiratory condition. • Stridor • Crowing • Gasping respirations • Snoring 6. Follow institution standard for Identiﬁ es need for pain • Continued pain despite pain assessing pain. Administer interventions. interventions analgesia as prescribed.

Documentation Documentation should include the following: • Patient and/or family education • Veriﬁ cation of proper placement • Insertion of nasopharyngeal or oropharyngeal airway • Method of adjunct securement, if any • Size of airway adjunct inserted • Appearance and character of airway secretions, if • Any difﬁ culties with insertion or unexpected outcomes present • Use of lubrication and/or topical anesthetics • Tissue integrity around airway adjunct • Patient tolerance, including respiration, vital signs, and pain assessments before and after procedure

References and Additional Readings For a complete list of references and additional readings for this procedure, scan this QR code with any freely available smartphone code reader app, or visit http://booksite.elsevier.com/9780323376624 .