What is the most serious potential complication of nasopharyngeal airway insertion facial trauma

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Introduction

Nasopharyngeal airways can provide significant airway protection for patients whose level of consciousness is decreased, but who maintain some airway reflexes and for whom oropharyngeal airways would prompt gagging or vomiting.  They are also useful for patients who exhibit trismus or have injuries to the mouth or jaw. 

Indications

• Patients who require an airway adjunct but who are unable to tolerate an oropharyngeal airway, or where an oropharyngeal airway is unable to be placed

Contraindications

• Significant maxillofacial trauma, particularly Le Fort fractures that include the zygoma(s)

Procedure

1. Select an appropriate size of nasopharyngeal airway by measuring a candidate airway against the patient’s face: measure the distance from the nostril to the tragus of the ear, holding the nasopharyngeal airway in its neutral position.  Do not straighten the airway to measure it.
2. Lubricate the barrel of the nasopharyngeal airway.  Avoid getting lubricant in the lumen.
3. Unless anatomy or injury dictates otherwise, select the largest nostril on the patient and insert the nasopharyngeal airway perpendicularly to the plane of the face.  Advance the airway straight back with a gentle but firm motion.  Some rotation may be necessary to overcome obstacles in the turbinate.  Do not use force to overcome resistance.
4. A jaw thrust is needed to ensure the epiglottis lifts off the laryngeal inlet.

Notes

• Epistaxis is the most common complication of nasopharyngeal airway placement.  This risk is higher in individuals who are taking anticoagulant medications.  If bleeding develops, leave the nasopharyngeal airway in place so long as it does not cause airway obstruction or compromise; otherwise, remove the airway and place the patient in a protective position.
• PCPs may not suction down the lumen of the nasopharyngeal airway.

Resources

References

Nasopharyngeal airways are flexible tubes with one end flared (hence their synonym: nasal trumpets) and the other end beveled that are inserted, beveled end first, through the nares into the pharynx.

Pharyngeal airways (both nasopharyngeal and oropharyngeal) are a component of preliminary upper airway management for patients with apnea or severe ventilatory failure, which also includes

• Proper patient positioning

• Manual jaw maneuvers

The goal of all of these methods is to relieve upper airway obstruction caused by a relaxed tongue lying on the posterior pharyngeal wall.

• Spontaneously breathing patients with soft tissue obstruction of the upper airway

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

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

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 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.

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; 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

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

• An oropharyngeal airway may be used concurrently with nasopharyngeal airways.

• Nasopharyngeal airways can usually be used even with major facial injuries.

• Although topical vasoconstrictors and/or anesthetics are sometimes used, no evidence indicates that they decrease complications or pain.

• 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, none in children with a large occiput, a large degree in obese patients).

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 obese patients, 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 use only the jaw-thrust maneuver or chin lift without head tilt to manually facilitate opening of the upper airway.

• 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.

• 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.

• 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.

The following are some English-language resources that may be useful. Please note that THE MANUAL is not responsible for the content of these resources.

• Roberts K, Whalley H, Bleetman A: The nasopharyngeal airway: Dispelling myths and establishing the facts. Emerg Med J 22:394-396, 2005.

• Roberts K, Porter K: How do you size a nasopharyngeal airway? Resuscitation 56, 2003.

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