The purpose of this guideline is to provide guidance about nasopharyngeal airways (NPA) at Great Ormond Street Hospital.
The NPA is a flexible endo-tracheal tube that is designed to open a channel between the nostril and the naso pharynx; it can either be used in the emergency or long-term use (Resuscitation Council Ltd 2006; Walker 2009). It aims to bypass upper airway obstruction at the level of the nose, naso-pharynx, or base of the tongue.
A correctly placed NPA will lie just above the epiglottis having separated the soft palate from the posterior wall of the oro-pharynx. This knowledge is vital if the NPA is to be sized correctly in patients: if the airway is too short it will fail to separate the soft palate from the pharynx and if too long it can either pass into the larynx and aggravate cough and gag reflexes (Roberts et al 2005).
The nasopharyngeal airway primarily acts as a "splint" which maintains patency of the airway, or keeps the tongue form falling back on the posterior pharyngeal wall and occluding the airway, therefore preventing airway obstruction, hypoxia and asphyxia (Dinwiddie 1997).
Nasopharyngeal airways are generally well tolerated by conscious children and used in the management of children with congenital maxillofacial abnormalities, syndromic craniosynotosis, mid facial hypoplasia or to support the upper airway post trauma or surgery (Walker 2009; Tweedie 2007).
Note: While the term 'child' is used throughout this guideline, all procedures are also applicable to young people.
Indications for inserting an NPA
Indications for the airway itself and the length required to relieve the obstruction is done on an individual basis for each child.
Pierre Robin Sequence
Pierre Robin Sequence (PRS) is characterised by an unusually small mandible (micrognathia), posterior displacement or retraction of the tongue (glossoptosis), and upper airway obstruction. Incomplete closure of the roof of the mouth (cleft palate) is present in the majority of patients, and is commonly U-shaped.
In PRS, airway obstruction is mostly due to glossoptosis, whereby the tongue occludes the airway, resulting in difficulty breathing. Upper airway obstruction results in a failure of airflow into the lungs, despite adequate inspiratory effort. Increasing respiratory effort can worsen the obstruction, as increased intra-thoracic pressure collapses the soft tissue structures inwards. PRS is seen in other syndromes including Stickler, Treacher Collins, and Velo-cardiofacial syndromes. The airway obstruction may be intermittent, and may also take time to develop, with some infants not presenting for days to weeks after birth, most commonly with failure to thrive due to ongoing increased work of breathing.
Craniofacial patients eg Apert, Crouzon, Pfeiffer, for the treatment of obstructive sleep apnoea. May be used for months or years, NPA often allows avoidance of tracheostomy. These children have anatomical mid facial hypoplasia which includes narrowed nasal passages, underdeveloped and setback mid-facial skeletal structures, malocclusion of the upper and lower jaws. Position of the tongue can occlude the airway. Children may present with symptoms of upper airway obstruction, feeding difficulties and failure to thrive.
Post cranio fronto-facial surgery
The NPA can be used to support the airway because of potential facial oedema. The NPA also acts as a barrier between the nasal mucosa and dura of skull base; this may help to prevent nasal bacteria infiltrating the dura. The NPA is usually sutured in place. In patients who have had trauma/facial surgery it is extremely important to remember the nasal cavity is quite vascular and aggressive attempts to insert an NPA can cause profound bleeding which will further compromise the difficult airway. Staff should only attempt insertion of an NPA if they are experienced in doing so and after consulting the child’s medical team.
Children with obstructive sleep apnoea are at risk of respiratory compromise following an adenotonsillectomy, due to post-operative oedema (Tweddie 2007).
The young age of the patient and severe sleep-related upper airway obstruction significantly increase this risk of airway obstruction:
usually for one to two nights post operatively
usually avoids a PICU admission
low threshold in sickle cell patients (to avoid hypoxia)
low threshold in patients with a narrow mid-face
low threshold in cerebral palsy/neurologically compromised patients
Only remove NPA on instructions from ENT surgeons. In patients who have had trauma/facial surgery it is extremely important to remember the nasal cavity is quite vascular and aggressive attempts to insert an NPA can cause profound bleeding which will further compromise the difficult airway.
Staff should only attempt insertion of an NPA if they are experienced in doing so and after consultation with the medical team.
Post cleft lip and palate repair
Occasionally a baby undergoing a unilateral/bilateral lip repair with anterior palate repair (vomerine flap) may require an NPA.
Often babies with Pierre Robin sequence (who may/may not have had NPA pre-op) will have an NPA post-operatively, due to closure of palate and post-operative oedema potentially causing airway obstruction.
Babies with isolated cleft palate, whose repair was tight (+/-) lateral releasing incisions, may have post-operative swelling requiring NPA.
The NPA is usually left in situ for one to two nights post-operatively. However some children may have an existing NPA in situ. This will be left in situ and managed long term by the respiratory team.
Only remove NPA on instructions of cleft surgeon. If the NPA is removed unexpectedly, practitioners should seek advice from the cleft surgeons as re-passing NPA can cause potential damage to cleft repair.
Airway obstruction is a common occurrence in paediatric resuscitation. It may be the primary cause of the cardio-respiratory arrest (eg choking) or a consequence of the underlying disease process (eg hypoxia), which leads to loss of consciousness. In unconscious children the tongue can fall backwards and occlude the airway. Regardless of the cause airway obstruction must be rapidly recognised and managed to prevent secondary hypoxic damage to vital organs.
In a conscious child, airway obstruction may be demonstrated by difficulty in breathing and/or increased respiratory effort. In either conscious or unconscious children there may be additional respiratory noises if the obstruction is partial, whereas respiration will be silent if there is complete obstruction.
Sizing of the nasopharangeal airway
In respiratory children only
The size and length of NPA is determined by:
obtaining the child’s crown to heel length as there is a positive correlation between this and the length of the NPA (see Appendix 1 (PDF))
referring to graph in Appendix 1 (PDF) to obtain approximate length of airway
referring to the lateral neck X-ray if appropriate
The correct diameter of tube must also be determined. If the airway is too narrow it will not be an effective airway; if it is too wide it may cause the skin to breakdown due to pressure points. This is dependent on the age of the child/infant. However, the length rather than the diameter is more pertinent in most cases.
Craniofacial and ENT patients
The NPA is tailor-made - depending on indication, anatomy, size and the age of the child, this is usually performed in theatre under direct vision.
The NPA is inserted under direct vision in theatre at the time of the palate repair. Those that have existing nasopharyngeal airways are inserted under the respiratory teams who use the crown to heel measurement chart as a guide.
Sizing of nasopharyngeal airway in emergency care
Measure the required length for the nasopharyngeal tube by measuring the tube from tip of the child’s nose to the tragus of their ear. The appropriate tube width/size can be estimated by matching its diameter against the opening of the child’s nostril; when inserted, it should not cause blanching of the nostril on insertion.
Insertion of a NPA
Ensure that the child/young person (if appropriate) and family are informed of the following to obtain consent and to maximise the effectiveness of the procedure:
the reason for the nasopharyngeal airway
what it will involve
the likely duration of the airways placement
the potential difficulties of using an airway
the likely impact on the child and family
If necessary, contact an appropriate play specialist, psychologist or nurse to work with the child.
Preparation of equipment and environment
The child’s bed area must be made easily accessible from both sides without obstruction, eg patient luggage, chairs etc, to ensure safe and unrestricted access to emergency equipment for staff.
Appropriate resuscitation and suction equipment
Note: All equipment must be checked whenever a practitioner takes over the care of a child with an NPA, including breaks and transfers to another ward/department. The child must never be left alone.
The accompanying carer (including parents where applicable), as a minimum, must be able to:
The child with a long term NPA should have an emergency NPA equipment box by the bedside containing:
a spare NPA (same size (ID) and length) if case the NPA needs to be changed
an NPA (one size smaller by 0.5mm) in case unable to re-pass usual size
a water-based lubricant such as Aqua lube® or KY jelly® to facilitate insertion
round-ended scissors to cut tape and or suture
roll of zinc oxide tape, eg Leukoplast™, to secure connector to face
goggles/protective eye wear should be available as per local infection control policy
suction catheters - correct size (refer to suctioning section)
hydrocolloid dressing, eg DuoDERM® to protect the skin
gauze for cleaning
clean gloves (as per local infection control policy)
clean receiver with tap water to flush suction tubing
2ml syringe and ampoule 0.9% sodium chloride for irrigation
orange clinical waste bag as per hospital policy
Inserting the NPA
Perform a hygienic hand wash (see hand hygiene guideline).
Prepare equipment/cut and secure naso-pharyngeal airway.
Ensure the child is swaddled (if appropriate).
Ensure the child’s nostrils are clear from secretions.
Ensure oxygen and suction is available at the bedside.
Wear non sterile gloves/apron/goggles as per universal precautions.
Insert nasopharyngeal airway gently into the nostril.
Do not force NPA into the nostril as this may cause unnecessary oedema and trauma. Summon more experienced help for example ENT or respiratory team, craniofacial or tracheostomy CNS.
Once inserted secure the NPA by passing the zinc oxide tape through the loops of the tracheal tube holder and then onto the hydrocolloid dressing on the face cheeks.
Clear away equipment according to the waste policy.
Whilst passing the NPA observe for any undue respiratory distress:
Immediately after insertion
Blanching of nares leading to pressure injury/ skin breakdown around the alar rim.
Milk/food coming up the airway before, during and after feeds, this may indicate that the NPA is too long. Note: A small amount of milk may initially be expected during feeds due to the close proximity to the epiglottis.
For craniofacial and respiratory patients with longer term NPAs, the length may have to be adjusted (discuss with consultant). In the short term, especially with ENT/cleft patients, a donut spacer may be used at the nares which can effectively shorten the length as a temporary measure, until the NPA is removed the following morning after surgery.
There is some enlargement of the nostril associated with NPA placement which may be permanent. If the tube is alternated between the two nostrils, for example in Pierre Robin patients, the chance of this occurring is reduced. In patients with mid-face hypoplasia one nostril only is generally used for NPA placement as changing sides is difficult in an already significantly narrowed passage. In these children also there is frequently dislocation of the septum away from the nostril in which the NPA is positioned. This can be surgically corrected when the child is older if it causes problems.
If the NPA is not inserted under direct vision (using a flexible endoscopy scope) a lateral neck X-ray may be performed as soon as possible to verify tube tip position. This is a medical decision and should be used in conjunction with other non-invasive assessments, including auscultation of the chest, child’s comfort and general observations.
The passing of a NPA must be recorded in the child’s health care records. This must include the length and the diameter of the ETT and the size of the tube holder. Communication between the hospital and community health carers must be commenced following insertion (long term NPA only) and a list of equipment must be sent.
In long-term cranio-facial patients the NPA may stay in for four to six weeks before it is changed initially under a GA, as they may require dilatations due to altered nasal anatomy.
In respiratory children the NPA may be changed weekly or as required this will be discussed with the child’s medical team.
Care of the skin
Clean the nostrils as required to prevent excoriation.
Change zinc oxide tape daily or as required.
Observe pressure areas for redness or breakdown
Use cushioned hydrocolloid dressing to protect any potential pressure points especially around the cheeks (optional).
If pressure points occur around the nostril cut this dressing into a small 'donut' shape to fit under the NPA where it meets the nostril.
Nasopharyngeal airway insertion algorithm
Place the patients head in the sniffing position unless contraindicated.
Lubricate the distal half of the tube with water-soluble lubricant.
With your index finger, push up on the tip of the patient’s nose and hold the nasal airway in your dominant hand.
Insert the tip of the tube into the (R) nostril gently thread the tube along the floor of the nasal passage perpendicular to the face until the flange is at the tip of the nose.
If unable to insert the NPA: summon more experienced help.
Care of the nasopharyngeal airway
Nursing actions during the few days following insertion of the NPA centre on maintaining the correct positioning and patency of the NPA, skin integrity and parental teaching (if appropriate to facilitate a safe patent airway, prevention of damage to skin of nares and cheeks and facilitate long term care needs and safe discharge with parents/carers competent in NPA care.
Initial observations and complications
The child’s vital signs should be recorded in accordance with local policy, with the frequency reducing or increasing as the child’s condition dictates.
Practitioners should also carry out routine non-invasive observations.
Check for air entry through NPA - place finger above the opening and feel for a passage of air flow.
Check that the NPA is secure.
Inspect the chest for bilateral chest movements, monitor work of breathing and report any concerns to the child’s/ young person’s medical team.
Airway suctioning is a common practice in the care of a child with a nasopharyngeal airway, it is undertaken to remove secretions from the child’s respiratory tract. Suctioning is associated with many potential complications and is now only recommended when there are clear indications that the patency or ventilation of the children could be compromised, However to prevent tube occlusion it is recommended that frequent suction is undertaken in the first 24-48hrs (Pritchard et al 2001; Czarnik et al 1991; Fiorentini 1992; Raymond 1995; Gemma et al 2002; Dellinger 2001; Spence et al 2003; Ahn & Hwang 2003; Prasad & Hussey 1995).
Main complications requiring suction interventions:
Practitioners trained in the skill should perform nasopharyngeal suctioning to minimise complications and maximise treatment (Nursing and Midwifery Council (NMC) 2008). The child and family must be informed of the reasons for suctioning, positioning, risks and outcomes as appropriate.
A 'clean' technique must be used and the catheter should be discarded if the tip is contaminated with hands, cot sides etc. Suction equipment must accompany the child at all times, regardless of the nature of the journey or the distance to be travelled.
The following equipment should be prepared:
suction catheters of the correct size
suction unit with variable vacuum control
apron (don if there is time - a child should never wait for suctioning)
tap water (in clean container)
2ml syringe with 0.9% sodium chloride for irrigation (not for routine suctioning)
orange waste bag
Practitioners must be aware that some pre-term, vulnerable infants and especially those who are requiring > 40% inspired oxygen, may require pre-oxygenation prior to suctioning to minimise a potential hypoxic event (Sigler & Willis 1985; Odell et al 1993; Pritchard et al 2001).
The amount and type of secretions should be observed, eg clear, milky, "crusty", copious etc. If there is a change in the colour or viscosity of the secretions a specimen should be sent for microbiological analysis. Excessive milk coming up the NPA should be reported to the child’s medical team, this may indicate that the NPA is too long.
Distal pharyngeal damage and hypoxia are very real and potential complications especially in the vulnerable paediatric airway. These complications may be reduced by having:
The correct size catheter. As a guide, practitioners should double the size of the ETT to obtain the appropriate catheter size, eg 4.0 ID ETT= size 8fg catheter. A suction catheter diameter should be less than half of the size of the ETT to reduce potential for hypoxia (Odell et al 1993; Glass & Grap 1995; Wood 1998; Ahn & Hwang 2003).
Catheters have one distal and two lateral holes with rounded ends which allow secretions to be collected both distally and laterally from the tube (Ahn & Twang 2003).
A lateral port that is smaller than the distal hole so that mucosal adhesion and biopsy does not occur (Fiorentini 1992; Luce et al 1998).
An integrated valve for vacuum control, as suction should only be applied on removal. Catheters should not be kinked prior to insertion in an effort to control the vacuum (Prasad & Hussey 1995).
It is preferable to use suction catheters with graduations, so that practitioners can measure the exact depth to be suctioned. Suctioning should not occur distal to the tube tip. Catheters should only be inserted so that the distal and lateral holes sit at the end of the tube. This allows collection of secretions but not trauma to the distal pharyngeal mucosa (Brodsky et al 1987; Runton 1992).
Suction pressures should be kept to a minimum; as a general guide pressures should not exceed 60-80mmHg (8-10kPa) for neonates/ small infants and up to 120mmHg < 16kPa for older children (Dean 1997; McElery 1996; Mowery 2002; Simpson 2001; Billau 2004; Young 1984). Excessive pressures can cause trauma, hypoxaemia and atelectasis (Czarnik et al 1991).
Suctioning is not a painful or distressing procedure; in fact, most infants will remain asleep throughout. If the child becomes distressed during suctioning then practitioners should revise their technique.
Constant observation of the child during suctioning is essential; practitioners should observe for an improvement or deterioration in respiratory rate and quality, child's colour, and oxygen saturations (if monitored).
Perform a hygienic hand wash (minimum alcohol gel rub).
Put on gloves.
Turn suction unit on and check the vacuum pressure is set to the appropriate level, according to the child's age.
The carer must know the length of the nasopharyngeal airway.
Insert catheter gently into the NPA, enough to ensure that the lateral and distal holes just pass through the tip of the tube, use the graduations on the catheter as a guide.
Handle only the proximal end of the catheter. Catheters should be discarded if the end has been touched before insertion.
Apply suction by placing thumb over the valve, found either on catheter. Do not kink the catheter/ suction tubing (Czarnik et al 1991).
Slowly withdraw the catheter without rotating out of the tube maintaining the vacuum. Do not apply suction on insertion as this may cause mucosal irritation, damage and hypoxia.
Suctioning should be quick but effective and should not exceed five to 10seconds (Sumner 1990; Young 1984), most of this literature is based on the adult population. In paediatrics, maximum durations should be based on the child's underlying medical condition and current clinical condition and practitioners should adjust timings accordingly, for example 10 seconds is a long time for a neonate with underlying lung disease.
The catheter may be re-used if immediate suction is required, as long as secretions have not occluded the suction ports (Scoble et al 2001).
Wrap the catheter around the gloved hand; remove the glove by inserting it over the used catheter and discard in orange waste bag according to the waste policy.
Flush suction tubing with tap water and connect a new catheter to the tubing.
Secretions become increasingly thick and tenacious, making their expulsion difficult because the NPA is bypassing the route for natural humidification; this may lead to blockage of the tube (American Thoracic Society 2000). Record if the secretions are bloody, purulent, foul smelling or unusually thick and report to the child’s medical team. Take samples as required.
Instillation of saline
Saline should not be used routinely (Blackwood 1999; Hudak & Bond-Domb 1996; Pritchard et al 2001; Ackerman & Mick 1990; Scoble et al 2001; Neill 2001).
The ill/hospitalised child may require extra humidity and this can be delivered via a nebuliser or by a continuous humidity system.
Nebulisers provide aerosol droplets in a saturated vapour. The advantage of using water droplets in the respiratory tract is not well documented or understood and some argue that excessive saturation of the lower airways may cause atelectasis and impair the function of distal cilia (Conway 1992; Harris 1967). For this reason nebulisers should be used as an addition to and not replace a primary method of humidification.
Water humidifiers are particularly useful when there is a higher requirement for humidification, for example, when the child requires a high minute volume during an acute respiratory illness or post anaesthesia (Klein 1974). This could be administered via a face mask.
Care must be taken when assessing the effectiveness of water humidifiers; water droplets must be visible along the whole of the elephant tubing. Warmed humidity must be used for small and vulnerable infants and those requiring oxygen.
It is also important that a child with an NPA remains systemically hydrated and practitioners should consider increasing the child’s intake during times of illness such as vomiting, diarrhoea, pyrexia, etc.
If the airway becomes blocked or it falls out it must be immediately replaced if indicated.
An emergency ‘box’ must accompany the child at all times and contain the following:
Oxygen, suction and resuscitation equipment must be kept by the child’s bedside.
Portable suction apparatus must accompany the child whenever they leave their bed area.
Nasopharyngeal airway emergency algorithm
Child has respiratory distress.
Check NPA patency. Suction: Try to clear tube. Administer oxygen.
Call for help. CSP Bleep 0313 on call anaesthetist 0510 and the child’s medical team.
If NPA is still blocked, remove the NPA but if fronto-facial monobloc/bipartition or post-op craniofacial children, do not remove.
Initiate BLS. Open the airway (head tilt, jaw thrust, chin lift). Consider an alternative airway support (Guedel/NPA). Call 2222 (Crash team).
Liaison must take place with the child’s local hospital and/or community team after insertion and an equipment list faxed to them (Appendix 3 (PDF)).
A child with a NPA may be discharged home whenever their condition is stable and when the parents/carers have been trained and are deemed competent to care for the NPA independently (Appendix 4 (PDF)).
The child should have appropriate follow-up according to their medical need.
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Document control information
Maureen Ferguson, Sister, Respiratory Medicine
Joanne Cooke, Nurse Practitioner, ENT
Kathy Truscott, Clinical Nurse Specialist, Craniofacial
Joanne Cooke, Nurse Practitioner, ENT
Kathy Truscott, Clinical Nurse Practitioner, Craniofacial
Kar-Binh Ong, Consultant, Anaesthesia
Michelle Wyatt, Consultant, ENT
Guy Thorburn, Consultant, Cleft lip and palate
Melanie Lindup, Consultant, Cleft lip and palate
Denise Welsby, Resuscitation Training Officer, Resuscitation Services
Heather Hatter, Practice Educator, Respiratory Medicine
Clinical Practice Committee (CPC)
First introduced 3 February 2003
Review schedule Two years
Date approved 2 February 2012
Next review 2 February 2014
Document version 2.0
Replaces version 1.0
In some guidelines it is necessary to use product names to ensure clarity of information or for the purpose of identifying a specific type of product or drug. Where possible, generic product names have been used in preference to trade names or trade marks. Please be aware that use of any trade names listed in this document should not necessarily be seen as an endorsement of the product and that other similar products may be available.