Nasopharyngeal Airway

Basic airway management in children and adults includes assessing and managing airway patency, oxygen delivery, and ventilation. All efforts should be taken to maintain airway patency noninvasively unless indications for invasive airway management are apparent. Passive oxygenation by nasal cannula or nonrebreather mask. Noninvasive positive pressure ventilation, as in BVM with a positive-pressure valve, continuous positive airway pressure (CPAP), and bilevel positive airway pressure (BiPAP). Supraglottic airways and laryngeal mask airway. Needle jet ventilation may be used in pediatric patients younger than 8 years. Cricothyroidotomy is appropriate for adults and children older than 8 years. Proper airway management begins by determining the best airway approach for the patient. Factors that can influence airway choice include obesity, macroglossia, evidence of trauma, cervical collar use, presence of a gag reflex, and age. After selecting the airway type, the patient's head is positioned for airway placement.

Methods for head positioning include the following: Head tilt-chin lift maneuver. One hand tilts the forehead while the other lifts the chin. Both actions extend the neck, reduce upper airway obstruction, and align the upper respiratory airways. This maneuver puts the patient in a sniffing position, with the nose pointed upward and forward. Chin lift: Both hands are placed underneath the mandible and chin. The mandible is then lifted until the teeth barely touch. Jaw-thrust maneuver: The spine is maintained in a neutral position. Then, the sides of the mandibular angle are lifted forward to lift the jaw and open the airway. This method is appropriate for individuals with a possible cervical spinal cord injury. Differences exist between the pediatric and adult airways. For example, prepubescent pediatric patients have a large occiput that can hyperflex the neck and obstruct the trachea. The head tilt-chin lift maneuver can correct this problem. However, care must be taken using this maneuver in children who have a weak trachea because neck overextension can also obstruct the airway. The head tilt-chin lift may be inadequate to keep the airway patent in children with a large, floppy tongue. The jaw-thrust maneuver is an alternative for these patients.

Once properly positioned, effective breaths must be delivered mouth-to-mouth or via BVM ventilation. If difficulties are encountered in delivering breaths, airway adjuncts like an oral pharyngeal airway (OPA) device or nasopharyngeal airway (nasopharyngeal airway) may be used to keep the airway patent (see Image. Airway Adjuncts). OPAs are appropriate for unresponsive patients. nasopharyngeal airway devices may be used on both unconscious and awake patients. Thus, nasopharyngeal airways are beneficial if intubation is not indicated or needs to be delayed. nasopharyngeal airway use may also be a temporizing measure if awake intubation is necessary. nasopharyngeal airways are hollow plastic or soft rubber tubes inserted into the nose and posterior pharynx. These devices should not cause patients to gag. Thus, nasopharyngeal airways are the best airway adjuncts for awake patients. These devices are also indicated for semiconscious patients with an intact gag reflex and may not tolerate an OPA. nasopharyngeal airways may also be useful when a patient's mouth is difficult to open, as in cases of angioedema and trismus. However, despite their many applications, nasopharyngeal airways only keep the airway patent in stable patients with spontaneous respirations or serve as a temporizing measure for patients needing an airway.

Intubation was traditionally a commonly performed airway management method among critical care and emergency physicians. However, most clinicians today prefer the intubation route, which has demonstrated better results and fewer complications than the method. Oral and maxillofacial surgery are the only disciplines where intubation is widely used. Studies have since found that using an nasopharyngeal airway before intubation during surgery improves the ease of tube insertion and minimizes bleeding during tube placement.

The preference is to insert an nasopharyngeal airway into the right nostril. This is because the natural curve of the nasopharyngeal airway and the flange bevel will open into the pharynx. If the standard nasopharyngeal airway is put in on the left nostril the bevel will sit against the pharyngeal wall and could become occluded. Explain rationale and procedure to child and family. Give the family the option of assisting or obtain other assistance if necessary. Check that the suction system is functioning and correct suction pressure is set. Attach a pulse oximeter to the child. If appropriate and with the help of the caregiver or assistant, gently wrap the child with a sheet or blanket to immobilise their arms and hands. Position the child on either side or back, at a 30-40-degree angle to facilitate and open the airway. Wash hands and put on gloves. Consider clearing the nostril by suctioning prior to insertion. A topical nasal decongestant may be applied 5min before nasopharyngeal airway insertion.

Frequently check the nostril for blanching or redness. If blanching occurs the airway is too tight and a smaller size is required. Patency of the nasopharyngeal airway can be checked by holding a metal teaspoon a few millimetres in front of the opening of the nasopharyngeal airway. As the child breathes the airflow through the nasopharyngeal airway will make a small patch of condensation (fogging) on the surface of the teaspoon. If the nasopharyngeal airway is blocked try using 0.9% NaCl drops (0.5 ml) and performing a suction. If this is not successful after 2 attempts the nasopharyngeal airway should be removed and a new nasopharyngeal airway inserted. The nasopharyngeal airway does not need to be routinely changed, however if it blocks or there is a build-up of crusting around the opening then it can be changed. The removed nasopharyngeal airway should be washed in soapy water, rinsed clean and kept as a spare tube (unless it shows signs of wear or has stuck on secretions that cannot be removed).

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