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 ❖ Patients with suspected basilar skull or cribriform plate KNOWLEDGE 5 fracture 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 5 therapy • 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 respira- tory care: A learning system , St. Louis, 1990, Mosby, 518.) Measure to tragus of ear Flange secured with safety pin and tape A 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 airways are generally used for temporary airway TABLE 9-1 Oral Airway Sizes 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 neu- rological 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